Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Lodge during CMS and state inspections, most recent first.
A resident who had been placed on 1:1 supervision due to multiple falls was left unattended when an assigned CNA left the room to go to the nurses’ station and plug in his phone. While the CNA was away, the resident got out of bed and fell, later being found to have facial fractures, including an orbital fracture and a LE Fort 1 fracture. The DON, NHA, and ADON confirmed the lapse in supervision and the resulting injury.
Insufficient clean linen and bedding were available, and staff could not state the facility par level for linens. Linen closets and carts were found with no towels, washcloths, flat sheets, or blankets, and staff reported daily trouble getting linen and problems with linen looking dirty and not clean. A resident was observed in bed with no linens while eating lunch, another resident said the facility runs out of linen, and a resident council member reported being bathed with towels and dried with pillowcases when standard items were unavailable.
Failure to properly substantiate neglect allegations: A resident reported being left wet overnight, and three other residents on the same assignment reported delayed call light response and missed or late incontinence/ADL care. The IDT unsubstantiated the allegation based on no skin impairments and residents denying distress, even though resident statements described delayed care and being left wet.
Accurate resident assessment was not maintained when two residents had incorrect MDS coding. One resident receiving hospice had an MDS that did not reflect hospice care and incorrectly answered the prognosis item, and another resident with an unstageable pressure ulcer present on readmission had an MDS that incorrectly showed zero ulcers present on admission or reentry. The MDS Coordinator and DON confirmed both assessments were inaccurate.
Care plans were not revised for four residents when their status or needs changed. One resident remained listed as potential discharge despite being LTC, another frequently slept in the dining room and refused redirection to bed, a third repeatedly declined having food cut into small bites and no longer received speech therapy, and a fourth had dialysis access changes that were not reflected in the care plan.
A facility failed to follow posted menus and tray cards for multiple residents’ meals. Several residents received chocolate ice cream or other desserts that did not match the posted menu or the tray card, and staff confirmed the mismatches during observation and interview.
Food storage and sanitation practices were not maintained in accordance with policy. Surveyors observed multiple opened and unlabeled foods, expired items, iced-over freezer storage, dirty dry storage conditions, water in clean adaptive cups on a lunch cart, dirty carts with spills and crumbs, and dirty snack coolers with a sticky substance. A utensil storage container also had handles not all facing the same direction, and the facility policy required foods to be labeled and dated and freezers to be kept clean and organized.
Improper Disposal of Garbage and Refuse in Kitchen: The facility failed to ensure garbage and refuse were disposed of properly in the kitchen. During an observation, eight boxes were found piled on the floor by the kitchen door, with gloves and wrappers in the top box, and torn pieces of paper were observed on the floor in the dry storage room. The garbage and refuse were confirmed by an employee.
Incomplete and inaccurate resident records were identified for three residents. A POST form lacked a dated representative signature, a transfer form contained an incorrect date for a resident’s acute care transfer, and a resident’s weight record showed a large one-week gain that was documented without being re-weighed as required by policy. The DON and ADON confirmed the record errors and the documented weight change.
Infection control practices were not maintained during medication administration when an LPN failed to perform hand hygiene before and after key tasks, including accucheck use, and after leaving a resident’s room before passing breakfast trays. Surveyors also found unsanitary conditions in two shower rooms and the laundry room, including overflowing trash, dirty linen on the floor, dirty floors, a dirty linen cart, and a dried brown substance on the laundry room floor.
Failure to provide needed nail care: A resident who was dependent for ADLs stated her nails needed to be cut, and staff observed the nails to be long and in need of filing on repeated checks. The DON said Activities usually provided nail care and confirmed that this care should have been provided, but did not confirm the nails had been trimmed until a later observation showed them appearing trimmed and filed.
Medication Left at Bedside: A resident was observed with two inhalers and a medication cup containing one TUM at the bedside. When asked about it, the resident said the medications had not yet been taken and that they were getting dressed and putting lotion on. An LPN acknowledged the issue, and the DON stated that medication is not supposed to be at bedside.
Oxygen therapy was not maintained as ordered for two residents. One resident's humidification bottle on the oxygen concentrator was empty, and an LPN said she would get a new bottle. Another resident reported using 4 L of O2 and having intermittent dyspnea, but the concentrator was observed set at 3.5 L; an LPN initially believed that was the ordered amount before confirming the order was for 4 L continuous via NC for COPD.
A resident receiving dialysis-related care had Sevelamer Carbonate/Renvela ordered once daily after hospital readmission, even though the medication is typically given 3 to 4 times per day with meals. The DON confirmed the order was based on the hospital discharge summary and had not been clarified with the dialysis physician.
A resident was observed not eating breakfast after being served cornflakes and two boiled eggs, despite a tray card indicating Fruit Loops, no eggs or pork, and assorted fruit juices. The resident stated she disliked the items served, and an RN confirmed the tray card and the meal that was delivered.
Therapeutic diet orders were not followed for two residents. One resident ordered large portions but received a regular-size meal serving, and another resident ordered small carb portions with large protein portions but received a regular-size protein portion. Staff confirmed the ordered portions were not provided, despite the tray cards reflecting the prescribed diets.
A resident reported missing multiple personal clothing items, which were not replaced or located by the facility despite a filed grievance and a promised resolution date. Staff attributed the delay to a broken washing machine and laundry backlog, leaving the issue unresolved.
Two residents did not have advance directives documented in their electronic medical records, resulting in both being automatically coded as Full Code. The Interim Administrator confirmed the absence of completed advance directives and stated that, without this documentation, residents are assigned Full Code status by default.
A resident experienced repeated delays in receiving prescribed medications, with several doses administered hours after their scheduled times. Facility staff confirmed that medications were not given within the required 60-minute window, and could not account for the delays on multiple occasions. This failure was identified during a survey and was not in accordance with the facility's medication administration policy.
A resident's catheter bag was improperly hooked to a transfer belt above the waist during a transfer, preventing proper drainage. This failure to maintain appropriate catheter care was confirmed by the DON, who stated the bag should have been kept below the waist to ensure proper flow.
A resident's personal refrigerator had multiple recorded temperatures above the facility's acceptable range and several days with missing temperature logs. A nursing assistant confirmed the incomplete documentation and elevated temperatures, which did not align with the facility's policy requiring daily monitoring and prompt notification of maintenance for out-of-range readings.
Two residents did not have their advance directives documented in their electronic medical records, as confirmed by the Interim Administrator, despite facility policy requiring documentation of resuscitation wishes.
Failure to Maintain Required 1:1 Supervision
Penalty
Summary
The facility failed to ensure Resident #3 was free from neglect when a nurse aide assigned to one-to-one supervision left the resident unattended to go to the nurses’ station to plug in his phone. The resident had been placed on 1:1 supervision because of multiple falls, and the aide stated he left the room while the resident was asleep and getting additional information about her. While the aide was away, the resident got out of bed and fell. After the fall, the resident was later sent to the emergency room and was found to have facial fractures, including a left inferior orbital wall fracture and a fracture of the left lateral maxillary sinus wall with associated hemorrhage and facial swelling/contusion. The report also states the resident was later noted to have a LE Fort 1 fracture. The incident was identified by the facility as neglect resulting in serious bodily injury, and the alleged perpetrator was the assigned nurse aide. The report indicates the resident had a prior fall and had been placed on 1:1 supervision after returning from the ER. During the incident in question, the required continuous supervision was interrupted when the assigned CNA was not in attendance with the resident. The DON, NHA, and ADON confirmed the event occurred and agreed the aide left the room and the resident fell and sustained fractures to the face.
Insufficient Clean Linen and Bedding Availability
Penalty
Summary
The facility failed to provide a safe, comfortable, home-like environment by not ensuring clean bed and bath linens in good condition were available for residents. The facility policy stated that par levels should be maintained to meet residents’ needs and that clean bed and bath linens in good condition must be provided, but staff were unable to state the par level for the facility when requested by the surveyor. On observation, the North Hall linen closet had no towels or washcloths, and the South Hall linen closet had only two towels, ten washcloths, and no flat sheets. Staff reported daily trouble getting linen and problems with linen looking dirty and not clean, and the Administrator stated she had called another facility to get more linen. Later review of linen carts found multiple carts with no washcloths, no blankets, no flat sheets, or only one towel or one blanket. Resident observations and interviews showed the impact of the shortage: one resident was lying in bed with no linens and had been served lunch in bed, another resident reported the facility runs out of linen and does not keep clean linen, and a resident council member reported being bathed with towels when washcloths were unavailable and dried with pillowcases when towels were unavailable.
Failure to Properly Substantiate Neglect Allegations
Penalty
Summary
The facility failed to correctly interpret the results of an investigation related to alleged neglect involving four residents. A facility-reported incident documented that one resident alleged she was not changed all night and was found soaked in the morning, while the assigned CNA stated she had checked and changed the resident multiple times overnight and last found her dry and asleep around 4 AM. The investigation also included interviews with other residents on the same assignment, and three additional residents reported delays in call light response time that night. Skin checks on those residents showed no new skin impairments, and they denied abuse, neglect, or psychosocial distress. Based on the absence of skin findings and the residents’ denials of distress, the interdisciplinary team unsubstantiated the neglect allegation. During survey review, statements taken from the residents showed additional concerns consistent with neglect. One resident stated she was not changed from the prior evening until the next morning and was soaked in bed. Another resident stated she did not receive incontinence or ADL care overnight. A third resident stated help was slow and she had to remain wet longer, and a fourth resident stated she needed to be changed and was not changed or gotten up at 6 AM. In interview, the Social Services Specialist stated the allegation was not substantiated because the residents denied feeling neglected and denied psychosocial issues, but then acknowledged that, after reviewing the definition of neglect, the allegation should have been verified.
Inaccurate MDS Coding for Hospice Status and Pressure Ulcer Admission Status
Penalty
Summary
Ensure each resident receives an accurate assessment was not maintained when the facility failed to keep accurate medical records for two residents in the areas of MDS and care planning. For Resident #12, the record showed admission to hospice services, but the significant change MDS with an ARD of 06/20/25 incorrectly answered No to the prognosis question asking whether the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months, and it also did not mark hospice care in Section O, even though the resident was receiving hospice services. For Resident #2, the record showed an unstageable pressure ulcer present upon readmission to the facility, but the MDS with an ARD of 03/17/26 coded one unstageable pressure ulcer and incorrectly recorded zero for the number of those ulcers that were present on admission or reentry. An interview with the MDS Coordinator and DON confirmed both MDS assessments were inaccurate and needed correction.
Care plans not revised for changed resident status, behaviors, and dialysis access
Penalty
Summary
The facility failed to ensure that care plans were revised for four residents when their conditions or preferences changed. Resident #5’s care plan still reflected a potential discharge status even though the Director of Nursing confirmed the resident was long term care and the plan had not been revised. Resident #22’s care plan also continued to reflect a short-term stay with possible discharge, while the resident was currently long term care. The resident reported frequently sleeping in the dining room at night, and staff observed the resident asleep there by herself with her head on the table, including during the overnight shift and at breakfast. A progress note documented repeated attempts to assist the resident back to bed, but the resident refused, and the care plan had not been revised for this behavior. Resident #63’s tray card directed staff to cut food into small bites, but the resident declined to have food cut up and stated he cut his own food. Staff confirmed he frequently refused this assistance, yet the care plan was not updated to reflect the declination. The resident’s care plan also included NMES applied during speech therapy, although the resident no longer received skilled speech therapy services. Resident #102 had a care plan focused on hemodialysis access and complications, including a PermCath to the right jugular, but the resident stated his fistula had been removed after infection and that a new dialysis access had been placed near his right shoulder. The DON confirmed the care plan was not updated to reflect removal of the fistula and the current location of the dialysis access.
Menu and Tray Card Mismatches
Penalty
Summary
Menus were not followed as posted and as stated on resident tray cards. The facility’s posted menu for 05/17/26 listed roasted turkey with gravy, carrots, oven browned potatoes, dinner roll or egg and sausage casserole, toast with butter and jelly, and vanilla ice cream, but tray cards observed varied and included vanilla ice cream, mixed fruit, and peanut butter pie for dessert. The Week at a Glance menu provided to the state surveyor for a Regular Liberalized diet stated vanilla ice cream, while the Therapeutic Lifestyle Change menu stated fruit sherbet. The facility policy for Menu Standards stated that daily menus would be posted and that the Week-at-a-Glance menu may be used when state regulations require portion size or posting of the entire week. During observation and staff interviews, several residents received desserts that did not match the posted menu or their tray cards. Resident #31 received chocolate ice cream even though the tray card stated peanut butter pie, and RN #3 confirmed the tray card and the dessert served. Resident #67 received chocolate ice cream and reported liking strawberry ice cream; Nurse Aide #42 confirmed the tray card stated peanut butter pie but the resident received chocolate ice cream. Resident #68 received chocolate ice cream, and Nurse Aide #30 confirmed the resident did not receive vanilla ice cream as posted; the tray card stated mixed fruit cup, but the resident received peaches and chocolate ice cream. Resident #17 received chocolate ice cream even though the tray card stated vanilla ice cream, and Nurse Aide #42 confirmed the mismatch. Resident #27 also received chocolate ice cream for dessert despite the tray card stating peanut butter pie, and Nurse Aide #23 confirmed the dessert served.
Food Storage and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During the kitchen investigation, surveyors observed multiple food storage and sanitation problems, including House Recipe Quick Oats that were not sealed, Muffin Mix that had been opened with a use-by date of 04/26, Cream Soup Base that had been opened with a use-by date of 05/15/26, and an iced-over freezer chest containing ice cream with two to three inches of ice throughout the chest. In the dry storage area, eight boxes were piled on the floor by the door with trash in the top box, and pieces of paper and dirt were present on the floor. Surveyors also observed food service items and equipment that were not maintained in a clean or properly labeled condition. Water was inside four clean adaptive cups on a cart ready for lunch, two dirty carts with spills and crumbs were observed with clean adaptive equipment on one of the carts, and sandwich bread was opened and not labeled. Salad Mix was opened, brownish in color, and past its use-by date of 05/14/26. A box of hamburger buns was opened and on the freezer floor, pepperoni slices were opened and not labeled, and two igloo coolers used for snacks were dirty with a sticky substance that rubbed off. On 05/19/26, the handles in a utensil storage container were not all facing the same direction. The facility policy stated that foods are to be labeled and dated, freezer foods are to be kept in original containers or covered and labeled, and freezers are to be kept clean and organized.
Improper Disposal of Garbage and Refuse in Kitchen
Penalty
Summary
The facility failed to ensure garbage and refuse were disposed of properly in the kitchen. During observation on 05/17/2026 at 10:15 AM, the kitchen investigation found eight boxes piled on the floor by the kitchen door, with the top box containing gloves and wrappers. Torn pieces of paper were also observed on the floor in the dry storage room. The garbage and refuse were confirmed by staff member #112 at 10:25 AM.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure an accurate and complete medical record for three residents. For Resident #62, the Physician Order for Scope of Treatment (POST) form was reviewed and the resident representative’s signature was found to be undated, which was confirmed by the ADON. For Resident #13, the record showed the resident was sent to an acute care facility on 02/25/26, but the transfer form listed an incorrect date of 06/17/25; the DON confirmed the date was incorrect. For Resident #15, the weights record documented a 40.8-pound gain in one week, with a weight of 114.2 lbs. on 05/04/2026 and 155 lbs. on 05/11/2026, and the facility’s policy stated that if a body weight is not expected, the resident should be re-weighed. The DON confirmed the documented weights and weight gain, and the ADON stated the issue was not caught until surveyors asked about it.
Infection Control Lapses During Medication Pass and Unsanitary Utility Areas
Penalty
Summary
The facility failed to maintain infection control practices during medication administration for two residents. While observing medication administration for Resident #53, the LPN did not perform hand hygiene before pulling medications, before completing an accucheck, after completing the accucheck, or after cleansing the glucometer with a sani-wipe. During medication administration for Resident #62, the LPN administered medications, then brushed the resident’s hair at the resident’s request, left the room without performing hand hygiene, and then began passing breakfast trays without performing hand hygiene. The facility also failed to maintain cleanliness in the East shower room, the [NAME] shower room, and the laundry room. In the East shower room, surveyors observed overflowing trash, bagged dirty linen spilling onto the floor from a trash can, and dirty brown floors; NA #106 confirmed these conditions. In the [NAME] shower room, surveyors observed overflowing trash, bagged dirty linen spilling onto the floor, and dirty brown floors; NA #41 confirmed these conditions. In the laundry room, surveyors observed dirty floors on both the clean and dirty sides, a torn brief on the floor, a dirty linen cart, and a dried brown substance on the floor on the dirty side.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to provide dependent residents with necessary ADL care for Resident #62's nail care. During an interview on 05/17/2026, Resident #62 stated, "Look at my nails, they need cut," and the nails were observed to be long and in need of filing. On 05/18/2026, the resident was again observed in her room and the nails remained long. On 05/19/2026, the DON stated that Activities usually provided nail care and that they were going to start doing manicures once or twice a month, and confirmed that nail care should have been provided by the Activities department, but did not confirm at that time whether the nails had been trimmed. On 05/20/2026, the resident's fingernails were observed to appear trimmed and filed.
Medication Left at Bedside
Penalty
Summary
The facility failed to ensure an accident-free environment, of which it has control, for the storage of medication for Resident #10. During an observation on 05/17/26 at 12:10 PM, two inhalers and a medication cup containing one TUM were found at the resident’s bedside. When asked whether medication was kept at the bedside, the resident stated, “I haven't taken them yet. I was getting dressed and putting lotion on.” At 12:13 PM, an LPN was asked whether the resident was supposed to have medication at bedside and responded, “My bad.” The DON was notified at approximately 12:30 PM and stated that medication is not supposed to be at bedside.
Oxygen Therapy Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure oxygen therapy was maintained for two residents. For Resident #124, an observation of the oxygen concentrator showed the humidity bottle was empty, and an LPN stated she would get a new bottle and that it should be on there. The Administrator later confirmed the humidity bottle should not be empty if used with oxygen therapy. For Resident #15, the resident reported being on 4 liters of oxygen and having difficulty breathing at times, but the oxygen concentrator was observed set at 3.5 liters. An LPN initially thought the resident was ordered 3.5 liters, then confirmed the order was for 4 liters and stated it was "a hair under." The resident's order directed oxygen at 4 L/min via nasal cannula continuously for COPD, and the care plan stated to administer oxygen as ordered/indicated. The facility policy stated to open the oxygen source and set the flow rate to achieve the prescribed flow rate or FiO2.
Dialysis Medication Ordered Outside Recommended Frequency
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis-related medication management. Resident #102 was discharged to the hospital and then returned to the facility on 04/28/26. A review of the physician orders showed that the resident had been ordered Sevelamer Carbonate 800 mg, 1 tablet by mouth with meals for hyperphosphatasemia, with that order in place before the hospital transfer. After readmission, a new order was entered for Renvela 800 mg, 3 tablets by mouth one time a day for CKD, starting 04/30/26. The record noted that this order was outside the recommended dose or frequency because the daily frequency was below the usual frequency of 3 to 4 times per day, and it stated, "Provider aware." During interview, the DON confirmed the medication had been ordered once daily on readmission because the hospital sent that order on the discharge summary, and it had not been clarified with the resident's physician at dialysis.
Resident Served Breakfast Contrary to Documented Preferences
Penalty
Summary
The facility failed to ensure that a resident was provided a diet that reflected her stated food preferences. Resident #22 was observed in the dining room on 05/19/26 not eating breakfast and stated she received cornflakes, which she did not like, and that she disliked hard boiled eggs. Her tray card indicated 2 bowls of Fruit Loops with "out" handwritten, no eggs or pork, and assorted fruit juices, but she was served cornflakes, two boiled eggs, and no juice. After surveyor intervention, the resident received two bowls of Fruit Loops because the delivery truck had just run. Registered Nurse #5 confirmed the tray card and the food the resident was served.
Therapeutic Diet Orders Not Followed
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered by the attending physician for two residents. Resident #31 had a diet order for a regular/liberalized diet with regular texture, thin liquids, and large portions, but during observation the resident’s lunch tray card stated large portions while the resident received a regular-size serving; RN #3 confirmed the serving was regular size. The resident’s care plan identified nutrition concern related to potential for inadequate po intake and GERD. Resident #68 had a diet order for a consistent carbohydrate diet with regular texture, thin liquids, small carb portions, large protein portions, and fruit instead of dessert, but during lunch observation the tray card stated large protein and the resident was served a regular-size portion of protein; Nurse Aide #30 confirmed the resident did not receive a large portion of protein.
Failure to Protect Resident's Personal Property and Ensure Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment by not taking reasonable care to protect a resident's personal property from loss and by not ensuring comfortable temperatures in the dining area. One resident reported missing several personal clothing items since their admission in March, including shirts, shorts, boxer briefs, and socks. The resident filed a grievance regarding the missing items, which was documented in the facility's grievance log with a resolution date that was not met. Staff interviews confirmed that the missing items had not been replaced, citing a broken washing machine and a backlog in laundry as reasons for the delay. The grievance remained unresolved beyond the stated resolution date.
Failure to Ensure Residents' Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to formulate an advance directive, as required. During record review, it was found that two residents did not have advanced directives documented in their electronic medical charts. Both residents were automatically coded as Full Code in the absence of an advance directive. The Interim Administrator confirmed that there was no completed advanced directive for either resident and stated that, without such documentation, residents are automatically assigned Full Code status.
Failure to Administer Medications Within Scheduled Timeframes
Penalty
Summary
The facility failed to administer medications to a resident according to the scheduled times as required by professional standards of practice and facility policy. Multiple instances were identified where medications were given outside the required 60-minute window, including delays of several hours for medications such as Lyrica, Lasix, Cholecalciferol, Potassium Chloride, Sennosides-Docusate Sodium, Wixela Inhub, Calcium Carbonate, Allopurinol, Tylenol, Apixaban, and Ipratropium-Albuterol. These delays were confirmed through a review of the Medication Administration Audit Report and were not in accordance with the facility's Medication Administration Policy, which mandates administration within 60 minutes of the scheduled time unless otherwise specified. During interviews, a resident reported frequent delays in receiving medications, stating that medications were never on time. The Unit Manager RN confirmed that on one occasion, a nurse's family emergency led to a delay, with a physician being notified, but could not provide explanations for other instances of late administration. The facility census at the time was 113, and the deficiency was identified as a random opportunity for discovery during the survey process.
Improper Catheter Bag Placement During Resident Transfer
Penalty
Summary
During an observation, therapy staff were seen transferring a resident from a wheelchair to a stretcher. During this process, the resident's catheter bag was hooked to the transfer belt being used for the transfer. The transfer belt was positioned above the resident's waist, which prevented the catheter from draining properly. This improper placement of the catheter bag did not allow for adequate drainage, as required for appropriate catheter care and to help prevent urinary tract infections. The Director of Nursing confirmed that the catheter bag should have been kept below the waist to maintain proper flow.
Failure to Maintain and Log In-Room Refrigerator Temperatures per Policy
Penalty
Summary
The facility failed to ensure that refrigerator temperatures in a resident's room were properly maintained and logged according to professional food service safety standards. Review of the temperature log for the resident's personal refrigerator revealed several recorded temperatures above the facility's acceptable range of 32-40 degrees Fahrenheit, specifically 45, 45, 48, and 46 degrees on multiple dates. Additionally, there were missing temperature recordings for several days. A nursing assistant confirmed both the elevated temperatures and the missing entries. The facility's policy requires daily temperature monitoring and documentation, as well as notification of maintenance if temperatures fall outside the acceptable range, but these procedures were not followed in this instance.
Failure to Maintain Complete Medical Records for Advance Directives
Penalty
Summary
The facility failed to maintain correct and complete medical records for two of thirty residents reviewed, as required by accepted professional standards. Specifically, on 06/17/25, advance directives were not found in the electronic medical charts for two residents. This was confirmed by the Interim Administrator, who acknowledged that the advance directives were missing from the medical records for these residents. The facility's own policy requires that patients' resuscitation wishes be documented in the medical record, but this documentation was not present for the affected residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 134 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beckley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Beckley | 1.3 mi | ★★★★★ | 7 | 0 |
| Beckley Healthcare Center | 3.1 mi | ★★★★★ | 21 | 0 |
| Raleigh Center | 5.3 mi | ★★★★★ | 13 | 0 |
| Hilltop Center | 9.1 mi | ★★★★★ | 15 | 0 |
| Hidden Valley Center | 13.2 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.