Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Pocahontas Center during CMS and state inspections, most recent first.
A resident attempted to elope from the facility, but staff failed to document the incident and did not notify the resident’s physician or responsible party. An LPN acknowledged the incident and reported it verbally to the DON, and the DON later confirmed the attempted elopement and the absence of any progress notes or notification records related to the event. This omission was identified during a complaint investigation, based on review of clinical records and interviews with staff.
A resident with dysphagia and recent pneumonia was served regular consistency milk and coffee instead of the ordered nectar thickened liquids, despite clear physician orders and care plan instructions. The resident drank the thin liquids and experienced coughing, and the inconsistency was confirmed by both a surveyor and the interim DON during a meal observation.
A resident who was totally dependent for transfers and required a total mechanical lift with two staff was moved from a geri chair to bed without the ordered lift. Surveyors observed two NAs enter the room, saw no lift present, and later found the resident in bed; one NA stated they stood the resident up and pivoted her to bed. The resident had a history of TBI, convulsions, falls, and dementia with behavioral disturbance.
The facility did not consistently provide enough nursing staff to meet the required minimum nursing hours per patient day (NHPPD) on multiple days, as confirmed by staff interviews and record reviews. This deficiency was identified over a review period involving 59 residents.
The facility did not include the required census information on four daily nurse staffing postings across multiple shifts, as confirmed by administrative staff. This deficiency was identified during a review of staffing records.
Residents were not informed of where to find the Ombudsman's contact information or how to contact OHFLAC to formally complain about care. During a Resident Council meeting, residents said they did not know the Ombudsman's name or where the information was posted, and the SW was unsure who the Ombudsman was. Review of council minutes showed no documented discussion of OHFLAC or Ombudsman information for several meetings.
Failure to Provide ADL Assistance: Two residents did not receive needed ADL support. One dependent resident had gaps in documented showers with no refusals noted, and the DON confirmed the showers were not provided within an acceptable timeframe. Another resident was observed in bed appearing disheveled, unshaven, and unkept, and the Corporate RN confirmed the resident needed to be cleaned up.
Incomplete and inaccurate resident medical record documentation: A resident’s POST form was left unsigned by the MPOA, another resident’s beneficiary notification review was delivered but never signed, one resident’s progress note incorrectly referenced an amputation site that was not documented in the chart, and a medication order for another resident listed an incorrect diagnosis for Cogentin, which the DON confirmed was wrong.
Binding arbitration agreement not thoroughly explained. The facility's agreement stated it waived the resident's right to a court trial by judge or jury, but the ADM described it as fully voluntary, said residents had 30 days to change their mind, and stated there was mediation before trial; when asked if a resident or family could sue or go to trial after signing, the ADM answered yes. During resident interviews, only one resident accurately answered questions about the signed agreement, while others did not remember or said a family member likely handled it.
A facility did not complete an accurate and thorough investigation for an abuse allegation, with errors found in the resident's capacity status, BIMS assessment dates, and the use of an incorrect name in the incident report. These documentation discrepancies were confirmed by a corporate RN.
Annual performance reviews for nurse aides were not completed as required, with three out of five aides missing their reviews by the due dates, as confirmed by facility leadership.
Failure to maintain resident dignity during treatment and rest. A resident with a fall-related scalp laceration and hematoma had lidocaine and 6 staples placed by the MD at the nurses’ station where staff and other residents could observe. Another resident was repeatedly observed asleep in a Geri chair in the hallway across from the nurses’ station, with the DON confirming she was kept there because she slept better in the chair than in bed.
A resident was not invited to participate in his care plan meetings and said he had never attended them. The SW reported there was no documentation that he was notified or attended, and his MPOA was invited but did not attend or respond.
A resident’s night stand was observed with the wood peeled off and particle board exposed. An RCA later confirmed the condition and stated that a new one would be obtained.
Failure to report a resident incident occurred when a resident sustained a hematoma to the head during a full body mechanical lift transfer. Staff noted one strap had not been unhooked and struck the resident’s head, and although education was documented, no Facility Reported Incident was completed for neglect.
A resident with severe dementia, behaviors, UTI, and dehydration was hospitalized and later stabilized with psych meds and supportive care. The facility denied readmission after the hospital reported an IM antipsychotic issue, but survey review found no current physician order for IM meds on the acute care med list and the reason for the denial could not be verified.
A resident’s MDS incorrectly marked hospice care as not received even though the resident had been placed on hospice before the ARD. The Corporate RN confirmed the MDS error during record review.
A resident’s care plan was incomplete across multiple focus areas, including pain management, ADL support, hospice services, and skin breakdown prevention. Several goals and interventions were left blank, and the Corporate RN confirmed the care plan had not been fully developed with multiple blanks present.
The facility failed to enter a physician order for a resident on hospice and failed to follow physician orders for late medication for two other residents. Record review showed the hospice service order was not entered until well after the resident had already been placed on hospice, and a Corporate RN confirmed the timing of the order entry.
A resident’s meal was not served at an appetizing temperature. An NA found the resident had not yet been fed, and when the tray was later tested, the hot items were below the required temp and the fruit was above the required cold temp. The CDM stated the tray had left the kitchen early and was one of the first placed on the cart.
Failure to perform hand hygiene during medication administration. An GPN touched the medication cart trash can lid twice while preparing meds for a resident and did not complete hand hygiene afterward. The GPN later confirmed hand hygiene should have been done, and the DON agreed.
A resident with a history of aggressive and inappropriate behaviors was not adequately managed, leading to multiple incidents of abuse towards other residents and staff. The facility failed to report these incidents, notify the physician and responsible parties, and implement effective interventions, resulting in an Immediate Jeopardy situation.
The facility did not maintain the dryer in a safe manner, as observed in the laundry room where lint traps were full and overflowing onto the floor. The Environmental Services Operations Manual requires lint screens to be cleaned after every load or every hour to prevent fire hazards. An employee acknowledged the fire risk posed by the overflowing lint traps.
The facility failed to provide the required RN coverage for eight consecutive hours daily. On one occasion, there was no RN on staff for the entire day, and on another, only 7.83 hours of coverage were provided. This deficiency was confirmed by the facility's scheduler and has the potential to affect all 67 residents.
The facility failed to complete a staff evaluation for a CNA. The evaluation was conducted by the DON, but a post-it note indicated that the CNA missed going over the review with the DON. The Scheduler confirmed that the evaluation was incomplete and should have been completed when the CNA returned.
The facility failed to ensure safe and sanitary food service practices, affecting all residents receiving nutrition from the kitchen. Staff did not wash hands or wear gloves before handling serving spoons, and kitchen staff did not wear beard restraints as required. These actions were contrary to the facility's policies on food preparation and staff attire.
The facility did not identify the necessary CNA and nursing competencies to meet resident care needs. Although the facility assessment marked nursing competencies as sufficient, the PIC and an assisting Administrator could not specify any required competencies for nursing staff. This deficiency was found during a random review of CNA/nursing competencies, potentially affecting many residents.
A facility failed to implement its Abuse Prohibition policy, leading to multiple incidents involving a male resident with a history of sexual behaviors and aggression. Despite numerous documented instances of inappropriate behavior, the facility did not report these to the physician or POA, nor did it conduct thorough investigations or follow-up assessments. Interviews revealed a lack of awareness and action from staff, and the facility's corporate Clinical Lead Nurse acknowledged the failure to implement the policy and report incidents appropriately.
The facility failed to report and investigate incidents of abuse involving a resident with a history of inappropriate behavior. Despite multiple documented incidents of verbal, physical, and sexual aggression, the facility did not notify the physician or the resident's POA, nor did they conduct necessary investigations. Staff interviews revealed a lack of awareness and reporting of abuse, and the facility's policy on abuse prohibition was not implemented, leaving residents unprotected.
The facility failed to investigate abuse allegations as per their policy, involving a male resident with a history of inappropriate behaviors. Despite documented incidents of verbal, physical, and sexual aggression, the facility did not conduct thorough investigations, notify the physician or POA, or protect residents from further harm. Staff interviews confirmed awareness of the behaviors, yet the facility's abuse prohibition policy was not implemented.
The facility was found to have expired medical supplies, including BD Blood Transfer Devices and urinary catheters, in the medication and supply storage room. This deficiency was confirmed by an RN and has the potential to affect many residents.
The facility did not ensure that residents received a substantial evening snack, as required by their policies. Two residents reported not being offered snacks for several weeks, while others had to request them from the nurse's station. The facility's policies state that snacks should be delivered to the nursing station and offered to every resident, but this was not consistently done.
The facility failed to prevent infections by storing clean resident clothing in a chemical closet on the dirty side of the laundry room, where it was in direct contact with a cleaning solution used for mops. An employee stated that unlabeled clothing is kept in this closet until claimed, acknowledging the contamination risk.
A facility failed to provide a dignified dining experience when an RN assisted a resident with eating while standing over the bed, despite an available chair. The RN was concerned about a laptop on the over-the-bed table and acknowledged the inappropriate action.
A facility failed to document the provision of information regarding advanced directives for a resident. A record review revealed the absence of an Advanced Directive, and a staff member confirmed that no documentation was present to show that the resident or their representative had been informed about implementing an Advanced Directive. The resident's representative wanted the resident to remain a DNR, and a care plan meeting was scheduled to discuss this further.
The facility failed to maintain a safe and homelike environment for residents. In one room, soiled privacy curtains with brown and red substances were observed and left unchanged. In another unit, a bedside nightstand had a torn laminate surface, exposing rough edges and particle board, posing a risk for skin tears. These issues were confirmed by a RN and the Corporate Clinical Lead.
The facility did not provide a means for residents to report grievances anonymously, as revealed during a resident council meeting. The admissions director acknowledged the lack of an anonymous submission system, despite the facility's policy requiring confidentiality for grievances, including those submitted anonymously.
A facility failed to notify the Ombudsman of a resident's hospital transfer after a change in condition with abnormal vital signs. The responsibility for notification was assigned to a Social Worker who was on medical leave, and the Clinical Reimbursement Coordinator confirmed that the notification was not completed.
The facility failed to notify resident representatives of the bed hold policy during transfers to the hospital for two residents. One resident was transferred due to abnormal vital signs, and another due to vomiting blood. In both cases, the required bed hold notifications were not completed, as confirmed by facility staff.
The facility failed to coordinate with the State-designated authority to ensure residents with mental disorders received appropriate care by not accurately completing or updating their PASSR forms. This deficiency was identified for three residents, whose PASSR forms were missing critical diagnoses such as Schizoaffective Disorder, PTSD, and Bipolar Disorder, as confirmed by facility staff.
A facility failed to monitor potential triggers for a resident with PTSD, despite the resident's multiple diagnoses and prescribed psychotropic medications. The care plan lacked specific interventions for PTSD, and the facility did not assess or document potential triggers, contrary to its policies. The Corporate Clinical Lead Nurse acknowledged these deficiencies.
The facility failed to update care plans for two residents when their care needs changed. One resident's care plan was not revised after their insulin was discontinued, and another resident's care plan did not reflect their current hospice status and inability to participate in activities. These issues were confirmed by the Corporate Clinical Lead.
A facility failed to report elevated blood glucose levels for a resident as per physician orders. The resident's blood glucose levels exceeded the specified threshold on multiple occasions, yet these were not communicated to the physician. This lapse was confirmed by the Corporate Clinical Lead.
A resident in a LTC facility did not receive timely incontinence care despite using the call bell to request assistance. A staff member turned off the call bell and delayed care until after meal trays were cleared, citing a non-existent policy about linen carts. The facility's Corporate Clinical Lead Nurse confirmed there was no such policy, acknowledging the resident should have received prompt care.
A facility failed to monitor potential triggers for a resident with PTSD, who was also diagnosed with dementia, schizoaffective disorder, bipolar disorder, and major depressive disorder. Despite being on psychotropic medications, there was no behavior monitoring documented, and the care plan lacked interventions for PTSD. The facility's policy requires identifying and mitigating triggers, but this was not done, as acknowledged by the Corporate Clinical Lead Nurse.
The facility failed to provide necessary social services for discharge planning and healthcare decision-making for two residents. One resident needed assistance with housing to be discharged, but the absence of a social worker left her without support. Another resident experienced a change in capacity, and a decision maker was not promptly appointed, leaving him without a designated person for medical decisions. The admissions department, lacking licensed social workers, could not adequately fill the gap, leading to these deficiencies.
A facility failed to monitor behaviors for a resident receiving psychotropic medication, as identified during a survey. The resident had multiple diagnoses, including PTSD and Schizoaffective Disorder, and was prescribed Fluphenazine and Seroquel. However, there was no documentation of behavior monitoring in the medication administration record, contrary to the facility's policy. The Corporate Clinical Lead Nurse acknowledged the lack of documentation.
A resident with multiple mental health diagnoses, including PTSD, had an incomplete medical record. The facility's Social Worker failed to document the PTSD diagnosis in the Social Determinants of Health assessment, and the care plan did not address PTSD. The Corporate Clinical Lead Nurse acknowledged the error.
The facility failed to post daily nurse staffing information in a prominent location, making it inaccessible to residents and visitors. Additionally, the staffing forms contained inaccuracies, such as incorrect CNA and RN numbers and hours, missing census data, and inclusion of administrative hours as direct care. The facility Scheduler confirmed these discrepancies.
Failure to Notify Physician and Responsible Party After Attempted Elopement
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and responsible party of a significant change in condition following an attempted elopement. During a complaint investigation involving a resident identified as #48, surveyors reviewed progress notes, the care plan, and the incident report log and found no documentation of the attempted elopement, no record of physician notification, and no record of notification of the resident’s responsible party. An LPN interviewed on 02/02/26 at 12:19 PM acknowledged that the attempted elopement occurred and stated she reported the incident to the Director of Nursing. The Director of Nursing, interviewed later that day, confirmed that the attempted elopement occurred on 01/17/26 and acknowledged that there were no records of notifying the physician or the responsible party and no progress notes pertaining to the incident. This lack of documentation and failure to notify the physician and responsible party of the significant change in the resident’s status constituted the cited deficiency, identified in the context of a facility census of 62 residents and focused on Resident #48’s attempted elopement event.
Failure to Provide Ordered Thickened Liquids for Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia, recent pneumonia, and COVID-19 was ordered to receive a pureed diet with nectar thickened liquids following recommendations from a speech language pathologist and physician orders. The resident's care plan and tray card specified the need for nectar consistency liquids due to aspiration precautions. Despite these orders, during a noon meal observation, the resident was served regular consistency milk and coffee by facility staff. The resident consumed the thin liquids and subsequently experienced coughing after drinking the milk. The surveyor reviewed the resident's tray card and confirmed that the liquids provided did not match the ordered nectar consistency. The interim DON was asked to verify the consistency and confirmed that the liquids were not thickened as required. This incident was identified during a random observation and was determined by the State Agency to have placed the resident at immediate risk for serious harm or death due to the failure to provide liquids in the prescribed consistency. The deficiency was based on direct observation, record review, and staff interview, confirming that the facility did not ensure the resident received liquids consistent with their individualized needs and physician orders.
Unsafe Transfer of Dependent Resident
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards when Resident #46 was transferred from a geri chair to bed without the required total mechanical lift. The resident was documented as totally dependent on staff for transfers, with care plan instructions for a full body lift for all transfers and dependent assistance of two staff members. Multiple lift transfer evaluations in the record, dated 10/31/23, 07/26/24, 10/24/24, 01/21/25, 04/22/25, and 07/22/25, all indicated the resident was to be transferred with a total lift and full body sling with two staff members. At approximately 2:15 PM, two nurse aides were observed entering the resident’s room while the resident was sitting in her geri chair. The surveyor maintained constant observation outside the room and saw the aides exit about 15 minutes later, after which the resident was found in bed and no mechanical lift was present in the room. When asked how the transfer was completed, one nurse aide stated that they stood the resident up and pivoted her to the bed, and confirmed that no lift was used. The resident’s record also noted yelling, grabbing staff, injury risk, and requiring reassurance, along with diagnoses including unspecified focal traumatic brain injury, unspecified convulsions, history of falling, and unspecified dementia with behavioral disturbance.
Failure to Meet Minimum Nursing Staffing Requirements
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident across all shifts, as required. A review of 45 daily nurse staff postings revealed that on 18 days within the review period, the minimum nursing hours per patient day (NHPPD) of 2.25 was not met. Specific days were identified where staffing levels fell below this threshold, with some days as low as 1.48 NHPPD. The facility census during this period was 59 residents. These findings were confirmed by both the Administrator and the Regulatory Compliance Advisor during staff interviews and record reviews. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to provide accurate and complete daily staff postings, as required. Record review revealed that on four occasions, the daily staff postings did not include the facility census for all shifts on specific dates. This omission was confirmed by both the Administrator and the Regulatory Compliance Advisor during staff interviews. The facility census at the time was 59 residents. The deficiency was identified through a review of 45 daily staff postings, with four postings missing the required census information for multiple shifts.
Residents Not Informed of Ombudsman and OHFLAC Contact Information
Penalty
Summary
The facility failed to ensure residents knew where the ombudsman's contact information was posted and failed to ensure residents were informed of their right to formally complain to the Office of Health Facility Licensure and Certification (OHFLAC) about the care they were receiving. The facility's Policy and Procedures for Grievances/Concern stated that residents have the right to voice grievances to the Center or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. During a Resident Council Meeting, residents reported they did not know the Ombudsman's name or where to obtain the contact information, and the resident serving as spokesperson stated she should know who the Ombudsman was but did not. The residents also reported they did not know where to find information to contact OHFLAC. The Social Worker was interviewed and was not sure who the ombudsman was at that time, though reported the ombudsman would sometimes attend Resident Council Meetings by phone. The surveyor later confirmed with Corporate Nurse #79 and the Corporate Compliance Officer that the residents did not know where the OHFLAC contact information was or where the ombudsman information was posted. The Resident Council Meeting Minutes reviewed did not show discussion of OHFLAC or Ombudsman information for several monthly meetings, and one month reflected ombudsman information only.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to provide activities of daily living assistance for dependent residents #6 and #11. Resident #6 was care planned as dependent for showers, but the shower record showed no documented shower from 08/24/25 through 08/29/25, with only showers documented on 08/29/25 and 08/30/25, and then no documented shower from 09/02/25 through 09/11/25; there were no refusals documented during either gap. On 09/24/25, the DON confirmed the dependent resident did not receive showers within an acceptable timeframe. Resident #11 was observed lying in bed appearing disheveled, unshaven, and unkept, and when asked how long it had been since he was able to shave, he replied, "it's been awhile." Shortly afterward, Corporate RN #72 entered the room and confirmed the resident needed to be cleaned up.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to ensure required documentation was completed and accurate in several resident records. Resident #60’s Physician Orders for Scope of Treatment (POST) form was dated in the signature area, but the resident’s Medical Power of Attorney did not sign the form even though the form stated a signature was required. Resident #70’s Beneficiary Notification Review form was delivered telephonically, but no signature was obtained and no follow-up was documented to obtain the signature. The facility also had inaccurate charting and an incorrect medication diagnosis in resident records. Resident #71’s progress notes stated that a skin issue was resolved at a location described as a below left elbow amputation site, but no documentation of an amputation was found in the medical record and the Administrator confirmed the resident did not have an amputation. For Resident #5, the physician order for Benztropine Mesylate (Cogentin) 1 mg by mouth twice daily listed schizoaffective disorder delusions, disorganized speech and thinking as the diagnosis, and the DON confirmed that the diagnosis for the medication was incorrect.
Binding Arbitration Agreement Not Thoroughly Explained
Penalty
Summary
The facility failed to thoroughly and accurately explain the Voluntary Binding Arbitration Agreement to residents or their representatives. The agreement stated that it waived the resident's right to trial in court by judge or jury and that arbitration was a complete substitute for a trial by jury, but during interview the Administrator stated it was fully voluntary, that residents had thirty days to change their mind, and that the facility had mediation before going to trial; when asked whether a resident or family could sue or go to trial once the agreement was signed, the Administrator answered yes. During resident interviews, Resident #20 was able to answer questions accurately about the signed agreement, while Resident #22 said, "I don't remember, but that is something I would sign," Resident #31 said she did not remember and stated, "I was out of it and sick" for about three weeks, Resident #15 said, "I don't remember," and Resident #13 said, "I don't know," adding that her daughter probably took care of it.
Failure to Accurately Investigate and Document Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough and accurate investigation was completed for a Facility Reported Incident (FRI) involving an allegation of abuse. Documentation errors were identified, including discrepancies in the resident's capacity status, incorrect dates for the Brief Interview for Mental Status (BIMS), and the use of an incorrect name in the report. The resident involved had been deemed incapacitated by the facility's physician, but the FRI summary incorrectly stated the resident was capacitated. These inconsistencies were confirmed by a corporate registered nurse, who acknowledged multiple errors in the FRI documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for nurse aides as required. During the survey, a review of five nurse aides' records revealed that three of the five had not received their annual performance reviews by the due dates. This finding was confirmed by both the Administrator and the Regulatory Compliance Advisor during staff interviews. No information regarding the medical history or condition of any residents was provided in relation to this deficiency.
Failure to Maintain Resident Dignity During Treatment and Rest
Penalty
Summary
The facility failed to provide a dignified experience for a resident who sustained an unwitnessed fall with a laceration to the back of the head and a large hematoma. The resident had a history of falls, right-sided hemiplegia, HTN, memory deficiency following CVA, afib, drug-induced subacute dyskinesia, vascular dementia, and vitreous degeneration. A change in condition was completed after the fall, and the facility physician was notified and came to the facility to evaluate the injury. The physician administered 3 cc of lidocaine and placed six staples in the resident’s head at the nurses’ station, where the procedure was observed by staff and residents rather than being done in a private setting. The resident was alert and oriented during the procedure, but the record and staff interview confirmed the treatment occurred at the nurses’ station. The facility also failed to provide a dignified sleeping experience for another resident who was repeatedly observed asleep in a Geri chair in the hallway across from the nurses’ station. The resident was seen sleeping in the chair on multiple occasions during the day and again after meals, with her head resting on the hand rail during one observation. The DON confirmed the resident was placed in the Geri chair because she slept better there than in bed, and later the interim DON instructed staff to lay her in bed when she was asleep. The observations documented the resident sleeping in the hallway near the nurses’ station rather than in a private or more appropriate setting.
Resident Not Invited to Care Plan Meetings
Penalty
Summary
Facility failed to ensure a resident was invited to participate in the development and implementation of his person-centered plan of care. The resident reported that he was not invited to his care plan meetings and had never attended them. A Social Worker stated that the resident did not receive invites to his care plan meetings and that there was no documentation showing he was notified of the meetings or attended them. The Social Worker also stated the resident does not like to leave his room often, and that his Medical Power of Attorney was invited but did not attend and did not respond.
Damaged Night Stand in Resident Room
Penalty
Summary
Resident #46’s night stand was observed with the wood peeled off, exposing particle board. The deficiency was identified during an observation on 11/04/25 at approximately 1:30 PM, and Regulatory Compliance Advisor #73 later confirmed the condition of the night stand at 3:10 PM, stating that a new one would be obtained.
Failure to Report Resident Head Injury During Lift Transfer
Penalty
Summary
The facility failed to ensure an incident was reported after Resident #37 sustained a hematoma to the head during a transfer using a full body mechanical lift. The resident’s care plan noted that the bar hit the resident’s head during the transfer while staff were following a two-person assist approach. The nursing description stated staff realized one strap was not unhooked, and when it was unhooked it came back and struck the resident on the left side of the head. Although an incident note documenting verbal education was completed and staff education was provided, a Facility Reported Incident was not completed for neglect. The Corporate Compliance Officer confirmed the incident was not reported and stated, “Didn’t report it.”
Denied Readmission After Hospitalization
Penalty
Summary
The facility failed to ensure Resident #71 was permitted to return to the facility after hospitalization. The resident was sent to an acute care facility for behaviors, a UTI, and severe dehydration, then remained hospitalized while awaiting placement on a psychiatric unit. Hospital records noted the resident continued to have behaviors after IV fluids and an antibiotic were given, was fearful and upset, and received one IM dose of Zyprexa. The hospital also documented plans to restart oral Zyprexa, possibly restart Depakote, and use Trazodone and Melatonin for sleep, with the nursing home planning to take the resident back when stable. Survey review found the facility had documented behaviors throughout the resident’s stay, but the resident was denied readmission after hospitalization. Hospital social services reported the denial was communicated as being due to receiving IM Haldol, and that the resident remained hospitalized due to finding placement. Facility leadership stated they were unaware of the denial or said it was being reviewed, and later stated the denial was at the corporate level. Review of the acute care medication list showed no current physician order for any IM medication, routine or PRN, from 09/17/25 through 10/07/25, and the reason for the denial of readmission could not be verified based on the medication list provided.
Incorrect MDS Hospice Coding
Penalty
Summary
Resident #9 had an MDS with an ARD of 07/30/25 that incorrectly indicated the resident was not receiving hospice care, even though the resident had been placed under hospice care on 07/23/25. During record review on 09/24/25, the facility’s Corporate RN confirmed that the MDS was incorrect.
Incomplete Care Plan for Hospice Resident
Penalty
Summary
Resident #9’s care plan was not developed completely and contained multiple blank sections across several focus areas. During the 09/24/25 record review, the care plan was missing interventions and goals under resistive to care related to cognitive loss/dementia, including the intervention to observe for pain, attempt non-pharmacologic interventions to alleviate pain, and document effectiveness. The care plan also had blank sections under at risk for decreased ability to perform ADLs related to chronic disease/condition, and under hospice care the goal statement was incomplete where it should have described how the resident would experience the highest practical quality of life as evidenced by specific measures. Additional hospice interventions were left incomplete, including chaplain, nursing, nursing assistant, and social work entries with blank frequencies and blank descriptions of services such as spiritual support, symptom management, comfort/pain, bowel function, ADL support, psychosocial support, and end-of-life care. The care plan also had incomplete interventions for risk for further skin breakdown, including pressure redistribution surfaces, turning and repositioning frequency, fluid encouragement, heel offloading, and bed surface guidance. The Corporate RN confirmed on 09/24/25 at 11:06 AM that the care plan had not been developed and multiple blanks were present.
Failure to Enter Hospice Order and Follow Late Medication Orders
Penalty
Summary
The facility failed to input a physician’s order for Resident #9 regarding hospice services and failed to follow physician’s orders for Resident #26 and Resident #27 regarding late medication. For Resident #9, record review showed the resident was placed under hospice services on 07/31/25, but the physician’s order was not entered into the record until 09/24/25. During interview on 09/24/25 at approximately 1:30 PM, Corporate RN #72 confirmed the resident had been under hospice services since 07/31/25 and that the physician’s order was entered on 09/24/25.
Meal Temperature Not Maintained
Penalty
Summary
Food and drink were not served at an appetizing and palatable temperature for Resident #46. During an observation, the resident was found in bed with her head at the foot of the bed and the bed wedge kicked out to the side. Nurse Aide #35 initially stated she did not know how much the resident had eaten and then discovered the resident had not yet been fed, stating she would feed her. A hallway tour found no other residents being assisted with meals and most lunch trays had already been collected. When the resident’s tray was returned to the hall and tested by the Certified Dietary Manager, the pureed carrots measured 112.8 degrees Fahrenheit, the pureed chicken casserole measured 114.6 degrees Fahrenheit, and the pineapples measured 67.5 degrees Fahrenheit. The CDM stated hot foods should have been 120 degrees or higher and pineapples should have been less than 41 degrees. The CDM also stated the cart with the resident’s tray left the kitchen at 12:15 PM and her tray was one of the first placed on the cart.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an infection control program during medication administration for Resident #19. On 11/04/25 at 8:24 AM, GPN #14 administered medications to Resident #19 and, while preparing the medications, touched the medication cart trash can lid two times without completing hand hygiene afterward. At 9:10 AM, GPN #14 confirmed that hand hygiene should have been completed after touching the trash can lid. At 9:20 AM, the DON was notified and also confirmed that hand hygiene should have been completed after touching the trash can lid. This deficiency involved 1 of 5 residents reviewed under the medication administration care area, with a facility census of 59.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse by another resident, identified as Resident #20, who exhibited physical, verbal, and sexually abusive behaviors towards other residents and staff. The incidents began on 04/19/23 and continued through 07/05/24, with at least 20 noted occurrences. The facility did not consistently report these behaviors as required, nor did they consistently notify the physician and responsible party. Additionally, the victims were not consistently identified, and interventions were not consistently implemented to prevent further abuse. Resident #20, a male resident with dementia and Alzheimer's disease, has a history of inappropriate sexual behaviors and aggression. Despite this, the facility failed to take adequate measures to manage his behaviors and protect other residents. Multiple incidents were documented where Resident #20 engaged in inappropriate touching, verbal aggression, and physical threats towards other residents and staff. These incidents were not properly reported or investigated, and the facility did not notify the physician or the resident's power of attorney as required by their policy. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the lack of investigations, follow-up assessments, and reporting of incidents. Interviews with staff revealed that they were aware of Resident #20's behaviors, yet no comprehensive actions were taken to address the situation. The facility's failure to adhere to its own policies and procedures resulted in an Immediate Jeopardy situation, putting residents at risk of serious harm.
Removal Plan
- Resident #20 was placed on one to one.
- The Director of Nursing (DON)/designee interviewed residents with Brief Interview for Mental Status (BIMS) of 7 or below if the resident permitted for potential sexual, verbal and physical abuse with any corrective action immediately upon discovery.
- Re-education was provided by the Director of Nursing (DON)/designee to all employees to ensure allegations of sexual, verbal, physical abuse are identified, immediate intervention put in place to prevent reoccurrence, immediately reported to the appropriate states agencies and thoroughly investigated.
- A post-test to validate understanding. Any employees not available during this time frame will be provided re-education, including post-test upon the beginning of next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee.
- The Director of Nursing (DON)/designee will monitor progress notes to ensure that allegations of sexual, verbal, physical abuse have been correctly identified, reported in a timely manner and appropriate intervention put in place to prevent the reoccurrence daily across all shifts including weekends and holidays, then 3 times a week then randomly thereafter.
- Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Failure to Maintain Dryer Safety in Facility
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible by not maintaining the dryer in a safe manner. During an observation of the laundry room, it was noted that the lint traps in the facility dryers were full and had overflowed with lint onto the floor. A review of the facility's Environmental Services Operations Manual revealed that lint screens must be brushed and cleaned after every load or every hour to prevent them from becoming packed with lint, which could block warm air and raise the temperature in the lint basket, creating a potential fire hazard. Employee #72 acknowledged the overflowing lint traps and recognized the associated fire risk.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for eight consecutive hours daily, as mandated by regulations. During a review of staffing posting forms, it was discovered that on March 18, 2023, there was no RN on staff for the entire day. Additionally, on April 9, 2023, the facility only provided 7.83 hours of RN coverage, falling short of the required eight hours. This deficiency was confirmed during an interview with the facility's scheduler, who acknowledged the lack of RN coverage on the specified dates. The absence of adequate RN staffing has the potential to affect all 67 residents currently residing in the facility.
Incomplete Staff Evaluation for CNA
Penalty
Summary
The facility failed to complete a staff evaluation for a Certified Nursing Assistant (CNA) identified as CNA #61. The CNA was hired on May 9, 2024, and the evaluation was conducted by the Director of Nursing (DON) on June 27, 2024. However, a small yellow post-it note was found covering the signature line for CNA #61, indicating that the employee missed going over the review with the DON. During an interview, the Scheduler acknowledged that the evaluation was incomplete and should have been completed with the staff member upon her return to the facility.
Deficiency in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that kitchen staff served food in a safe and sanitary manner, which had the potential to affect all residents receiving nutrition from the facility's kitchen. During an observation, staff did not properly wash hands with soap and water or wear gloves before handling serving spoons. Specifically, a staff member exited an office without washing hands or wearing gloves and handled serving spoons, which were then passed to another staff member to use in the serving line. This was acknowledged by the staff, who then washed hands, changed gloves, and replaced the serving spoons. Additionally, the facility staff failed to wear beard restraints as required by current food code requirements. Kitchen staff were observed working on the serving line without beard restraints, which was acknowledged, and they subsequently wore the required restraints. The facility's policy for food preparation and kitchen staff attire mandates proper handwashing techniques, glove use, and the wearing of approved attire, including hair nets or caps and facial hair restraints.
Failure to Identify Required Nursing Competencies
Penalty
Summary
The facility failed to identify the necessary Certified Nurse Aide (CNA) and nursing competencies required to meet the care needs of the resident population. During a review of the facility assessment, it was noted that the care areas of the resident population were outlined, and under the section for staffing, training, services, and personnel, the required nursing competencies were marked as sufficient. However, during an interview with the Person in Charge (PIC) and an assisting Administrator, they were unable to identify any specific competencies required for the nursing staff to complete. This deficiency was discovered during a random review of CNA/nursing competencies as part of the long-term care survey process, potentially affecting more than a limited number of residents in a facility with a census of 67.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy, which led to multiple incidents involving a male resident with a history of sexual behaviors and aggression. This resident, who has dementia and Alzheimer's disease, was involved in an incident where he was witnessed grabbing the breast of a female resident. Despite being placed on every 15-minute checks following the incident, the facility's records revealed a pattern of escalating behavioral disturbances by this resident, including verbal, physical, and sexual aggression towards other residents and staff. The facility's documentation showed numerous instances where the resident exhibited inappropriate and aggressive behaviors, such as making vulgar comments, threatening other residents, and attempting to touch staff and residents inappropriately. These incidents were not reported to the physician or the resident's Power of Attorney (POA), as required by the facility's policy. Additionally, the facility failed to conduct thorough investigations or follow-up assessments to ensure the safety and psychosocial well-being of the affected residents. Interviews with facility staff revealed a lack of awareness and action regarding the resident's behaviors. The facility's corporate Clinical Lead Nurse acknowledged that no investigations had been performed related to these incidents, and the facility's policy on abuse prohibition had not been implemented. The facility also failed to report these incidents to the appropriate authorities or address them in the Quality Improvement Committee, further highlighting the deficiency in handling and preventing abuse within the facility.
Failure to Report and Investigate Abuse Incidents
Penalty
Summary
The facility failed to report incidents of abuse, neglect, or theft to the appropriate state agencies as required by their policy and procedure entitled, Abuse Prohibition. This failure was identified during a review of facility-reported incidents and staff interviews. Specifically, an incident involving Resident #20 and Resident #22 was not reported appropriately. Resident #20, who has a history of sexual behaviors and inappropriate touching, was witnessed grabbing Resident #22's breast. Despite immediate intervention by staff, the incident was not reported to the necessary authorities as per the facility's policy. Resident #20 has a documented history of escalating behavioral disturbances, including verbal, physical, and sexual aggression towards staff and other residents. Multiple entries in Resident #20's medical record detail incidents of inappropriate behavior, such as making vulgar comments, threatening other residents, and inappropriate touching. Despite these documented behaviors, there was a consistent failure to notify the physician or the resident's Power of Attorney (POA) about these incidents, as required by the facility's policy. Interviews conducted with facility staff revealed a lack of awareness and reporting of sexual abuse incidents. RN #33, who conducted the investigation into the incident involving Resident #20 and Resident #22, failed to interview Certified Nursing Assistants (CNAs) or other staff who might have witnessed abuse. Additionally, the facility's corporate Clinical Lead Nurse acknowledged that no investigations or follow-up assessments were conducted for the incidents documented in Resident #20's progress notes. The facility's failure to implement its Abuse Prohibition policy resulted in a lack of protection for residents from further harm.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse as per their policy and procedure titled 'Abuse Prohibition.' This deficiency was identified during a review of facility-reported incidents and staff interviews. Specifically, an incident on July 2, 2024, involved a male resident with a history of sexual behaviors inappropriately touching a female resident. Despite the incident being reported to a Licensed Practical Nurse and documented, the facility did not conduct a thorough investigation, as evidenced by the lack of interviews with Certified Nursing Assistants who witnessed the event. The male resident involved in the incident had a documented history of escalating behavioral disturbances, including verbal, physical, and sexual aggression towards staff and other residents. Multiple entries in the resident's medical record detailed inappropriate behaviors, such as making vulgar comments, threatening other residents, and inappropriate touching. Despite these documented behaviors, there was a consistent failure to notify the physician or the resident's Power of Attorney, and no investigations were conducted for these incidents. Interviews with facility staff revealed awareness of the male resident's behaviors, yet the facility's policy on abuse prohibition was not implemented. The facility failed to protect residents from further harm, did not report or investigate incidents as required, and did not notify the physician or family members of the occurrences. Additionally, the facility did not conduct follow-up assessments to evaluate the psychosocial welfare of the affected residents, nor were these incidents addressed in the Quality Improvement Committee.
Expired Medical Supplies Found in Storage
Penalty
Summary
The facility failed to adhere to currently accepted professional principles regarding the management of expired medical supplies. During an observation of the medication and supply storage room, surveyors found two boxes of BD Blood Transfer Devices, each containing 50 devices, with an expiration date that had passed. Additionally, twenty urinary catheters of various sizes and volumes were discovered to be expired. These findings were confirmed by a registered nurse during the survey. This deficiency has the potential to affect more than a limited number of residents in the facility, which has a census of 67.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to provide a substantial and nourishing snack between the evening meal and breakfast, affecting residents without a dietary order for an evening snack or those unable to request snacks due to cognitive or physical limitations. During a resident council meeting, two residents reported not being offered bedtime snacks for several weeks, while two others mentioned having to request snacks from the nurse's station. A review of the facility's Food and Nutrition Service Policies and Procedures indicated that snacks should be delivered to the nursing station at specific times and offered to every resident by nursing or designated staff. An interview with a registered nurse revealed that nurse aides are responsible for taking the snack cart to each room to offer snacks every evening.
Improper Storage of Clean Clothing in Chemical Closet
Penalty
Summary
The facility failed to prevent infections through indirect contact transmission by improperly storing clean resident clothing in the chemical closet of the laundry room. During an observation, it was noted that several items of personal resident clothing were hanging in the chemical closet, which is located on the dirty side of the laundry room where soiled linen is brought for laundering. These clothing items were in direct contact with a Rapid Multi-Surface Cleaner, which is used for mops in the facility. The cleaning solution was also stored on the floor, further increasing the risk of contamination. An interview with an employee revealed that personal resident clothing is hung in this closet after laundering if it is not labeled and cannot be directly delivered to the appropriate resident. The employee stated that staff check this closet when a resident is missing an item. The employee acknowledged the potential for contamination of the clothing by the cleaner stored on the floor.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident during a long-term care survey. This deficiency was observed when a Registered Nurse (RN) was assisting a resident with eating while standing over the resident's bed. The resident had a laptop on the over-the-bed table alongside the dinner tray, and an empty chair was available on the right side of the bed. The Clinical Reimbursement Coordinator RN noted that the assisting RN was new and should not have been standing over the resident. The assisting RN acknowledged the inappropriate action and expressed concern about the laptop's placement, indicating she would move the chair to assist the resident while seated.
Lack of Documentation for Advanced Directive
Penalty
Summary
The facility failed to ensure that a resident had documentation related to the provision of information regarding advanced directives. During a record review, it was found that there was no documentation of an Advanced Directive for the resident. An interview with a staff member confirmed that there was no evidence that the resident or their representative had been provided with information about implementing an Advanced Directive. The staff member mentioned that a call had been made to the resident's representative, who expressed a desire for the resident to remain a Do Not Resuscitate (DNR). A care plan meeting was scheduled to discuss this further with the resident's representative.
Deficiencies in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations and staff interviews. In room A1-1, two soiled privacy curtains were observed, one with a brown substance and the other with both a brown substance and red spots. These curtains remained unchanged upon a follow-up observation the next day, which was confirmed by a Registered Nurse and the Corporate Clinical Lead. Additionally, in Unit B, the bedside nightstand in room A was found to have one-third of its top surface laminate torn off, exposing rough edges and particle board underneath. This condition was acknowledged by a Registered Nurse as unsafe for residents due to the potential for skin tears and not conducive to a homelike environment.
Failure to Ensure Anonymous Grievance Reporting
Penalty
Summary
The facility failed to ensure that residents could report grievances anonymously, as discovered during a resident council meeting. Residents expressed their inability to file grievances without revealing their identity. An interview with the admissions director confirmed that there was no system in place for anonymous grievance submission, as grievances were typically handed directly to her or the administrator. A review of the facility's Grievance/Concern policy indicated a responsibility to maintain confidentiality, including for grievances submitted anonymously, highlighting a discrepancy between policy and practice.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital, which was identified during a long-term care survey. This deficiency was noted for one of the three residents reviewed for hospitalizations. Specifically, the medical record review for a resident revealed that the resident experienced a change in condition with abnormal vital signs, leading to an order for hospital transfer. However, there was no documentation of notification to the Ombudsman regarding this transfer. During an interview, the Clinical Reimbursement Coordinator (CRC) acknowledged that the notification responsibility fell to the Social Worker, who was on medical leave at the time. The CRC admitted that the notification was not completed, indicating a lapse in the facility's protocol for notifying the Ombudsman in the absence of the designated staff member.
Failure to Notify Resident Representatives of Bed Hold Policy
Penalty
Summary
The facility failed to notify resident representatives of the bed hold policy at the time of transfer or discharge, as required by their policy. This deficiency was identified during a long-term care survey process, where two residents were reviewed for transfers or discharges. For Resident #68, a medical record review revealed that the resident was transferred to the hospital due to a change in condition involving abnormal vital signs. However, the medical record lacked documentation of a bed hold notification to the resident's medical power of attorney. The facility's Admission Director confirmed that the notification was not completed and was unable to provide a reason for this oversight. Similarly, for Resident #51, the medical record review showed that the resident was transferred to the hospital after experiencing vomiting that appeared to be blood. Again, the medical record was missing the required bed hold notification. The facility's Corporate Clinical Lead Nurse acknowledged the omission and stated that the notification should have been completed but did not know why it was not. A review of the facility's policy and procedure on discharge and transfer confirmed the requirement to immediately inform the resident or their representative in writing about the transfer, in a language they understand.
Failure to Coordinate PASSR for Residents with Mental Health Needs
Penalty
Summary
The facility failed to coordinate with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs when completing or revising a Pre-Admission Screening and Resident Review (PASSR). This deficiency was identified during a long-term care survey process for three residents. For Resident #57, the PASSR did not include several medical diagnoses such as Schizoaffective Disorder Bipolar Type, Delirium, Major Depressive Disorder, and Anxiety Disorder, which were confirmed by the Admissions Director as necessary to be included. Similarly, Resident #43's PASSR was missing diagnoses of Post Traumatic Stress Disorder, Paranoid Schizophrenia, and Delusional Disorders, which were also confirmed by the Admissions Director. For Resident #16, the PASSR lacked documentation of Post Traumatic Stress Disorder and Bipolar Disorder, as acknowledged by the facility's Corporate Clinical Lead Nurse. These omissions indicate a failure to accurately complete and update the PASSR forms, which are crucial for ensuring appropriate care and services for residents with specific mental health needs.
Failure to Monitor PTSD Triggers in Resident
Penalty
Summary
The facility failed to monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). This deficiency was identified during a review of the resident's medical record, which revealed that the resident had multiple diagnoses, including PTSD, unspecified dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and major depressive disorder. Despite these diagnoses, the resident's care plan did not include any specific interventions or monitoring related to PTSD. Additionally, the medication administration record showed no behavior monitoring for the psychotropic medications prescribed to the resident. The facility's policy on behavior management and trauma-informed care requires staff to identify and document behavioral symptoms and potential triggers for residents with a history of trauma. However, the facility did not assess the resident for potential triggers or implement trigger-specific interventions. The Corporate Clinical Lead Nurse acknowledged the absence of a care plan for PTSD and the lack of assessment for potential triggers, indicating a failure to adhere to the facility's policies and procedures.
Failure to Revise Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to revise the care plan for Resident #25 when their care needs changed. Initially, the care plan created on 11/16/23 indicated that Resident #25 was insulin-dependent. However, the resident's Lantus insulin was discontinued on 07/25/24, and the care plan was not updated to reflect this change. This oversight was confirmed by the Corporate Clinical Lead on 07/31/24. Similarly, the care plan for Resident #44 was not updated to reflect her current condition. Observations on 07/29/24 showed that Resident #44, a hospice resident since 06/18/24, was frail, bed-bound, and at the end of life. Despite this, the care plan included activities and goals that were not appropriate for her current state, such as attending out-of-room activities and maintaining the ability to feed herself. This discrepancy was also confirmed by the Corporate Clinical Lead on 07/31/24.
Failure to Report Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders regarding the reporting of elevated blood glucose levels for a resident. The resident had specific orders to monitor blood sugars twice weekly and notify the physician if levels were below 60 mg/dl or above 300 mg/dl. Despite this, there were multiple instances where the resident's blood glucose levels exceeded 300 mg/dl, specifically on four consecutive days, and these were not reported to the physician as required. This oversight was confirmed by the Corporate Clinical Lead, who acknowledged that the elevated levels should have been communicated to the physician.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was incontinent of bladder. On the morning of July 29, 2024, the resident indicated that they were incontinent and had used the call bell to alert staff for assistance. However, a staff member turned off the call bell and informed the resident that they would return after the lunch trays were picked up. The resident was left waiting for incontinence care, which was only provided after the surveyor intervened and informed the staff member responsible for the resident's care. The staff member, Employee #43, acknowledged the resident's need for care but stated that incontinence care was not provided during meal times due to a restriction on having linen carts in the hallway simultaneously with meal carts. This practice was not supported by any facility policy, as confirmed by the facility's Corporate Clinical Lead Nurse. The nurse acknowledged that the resident should have received prompt care when requested, indicating a lapse in the facility's care procedures.
Failure to Monitor PTSD Triggers and Implement Care Plan
Penalty
Summary
The facility failed to monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). This deficiency was identified during a review of the medical record of a resident who had multiple diagnoses, including PTSD, unspecified dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and major depressive disorder. The resident was prescribed psychotropic medications, including Fluphenazine and Seroquel, but there was no behavior monitoring documented in the medication administration record (MAR) for these medications or the associated diagnoses. Additionally, the resident's care plan did not include any specific interventions related to their PTSD. The facility's policy on trauma-informed care requires the identification of triggers that may re-traumatize residents and the implementation of trigger-specific interventions, which should be included in the care plan. However, the facility failed to assess the resident for potential triggers and did not develop a care plan addressing the PTSD diagnosis. This oversight was acknowledged by the facility's Corporate Clinical Lead Nurse during an interview.
Deficiency in Social Services for Discharge Planning and Decision Making
Penalty
Summary
The facility failed to provide necessary social services for discharge planning and appointment of a healthcare decision maker for two residents. Resident #62 expressed a desire to be discharged and live independently but required assistance in securing housing. The resident had been without a social worker for several months, and the last documented social services notes were from March 2024. These notes indicated that the social worker was assisting with discharge planning, including housing applications and social security benefits. However, since the social worker's absence, there was no follow-up, leaving the resident without the necessary support to transition out of the facility. Resident #48 experienced a change in capacity status, regaining capacity temporarily before losing it again. Despite this change, the facility did not promptly appoint a healthcare decision maker. The resident's niece, who had previously served as a surrogate, was not contacted to resume this role until after surveyor intervention. The delay in appointing a decision maker left the resident without a designated person to make medical decisions during the period of incapacity. The facility's lack of a social worker due to medical reasons contributed to these deficiencies. The admissions department, which was not equipped with licensed social workers, attempted to fill the gap but was unable to provide the necessary support for discharge planning and decision-making processes. This resulted in inadequate social services for the residents involved, impacting their ability to transition out of the facility and manage their healthcare decisions effectively.
Failure to Monitor Behaviors for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to monitor behaviors for a resident receiving psychotropic medication, which was identified during a Long Term Care Survey Process. The deficiency was noted for one resident, identified as Resident #16, out of five residents reviewed for unnecessary medications. Resident #16 had multiple diagnoses, including Post Traumatic Stress Disorder, Unspecified Dementia, Schizoaffective Disorder, Bipolar Disorder, and Major Depressive Disorder, all dated 03/20/24. The resident was prescribed Fluphenazine and Seroquel for schizoaffective disorder, but there was no evidence of behavior monitoring in the medication administration record. The facility's policy on behavior management requires staff to monitor and document any exhibited behavioral symptoms in the medical record. However, upon review, it was found that there was no documentation of behavioral monitoring for Resident #16. The facility's Corporate Clinical Lead Nurse acknowledged the lack of documentation and confirmed that behavioral monitoring should have been recorded in the resident's medical record.
Incomplete Medical Record for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, as identified during a Long Term Care Survey. The resident, who had multiple diagnoses including Post Traumatic Stress Disorder (PTSD), unspecified dementia, schizoaffective disorder, bipolar disorder, and major depressive disorder, was receiving psychotropic medications for schizoaffective disorder. However, the facility's Social Worker did not document the PTSD diagnosis in the resident's Social Determinants of Health assessment. Additionally, the resident's care plan lacked any reference to the PTSD diagnosis. The facility's Corporate Clinical Lead Nurse acknowledged the inaccuracy in the resident's assessment.
Inaccurate and Inaccessible Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information in a prominent location, as required. During a tour of the front entrance, it was observed that the staffing posting form was not visible for residents and visitors. The Admissions Director acknowledged that the form should be posted at the front of the building for easy access. Instead, it was located at the Director of Nursing's office, which is not a prominent location accessible to all residents and visitors. Additionally, the facility's staffing posting forms contained missing and inaccurate data. On several occasions, the forms inaccurately reported the number of direct care Certified Nursing Assistants (CNAs) and Registered Nurses (RNs), as well as their hours. The forms also used decimals to represent staff numbers, which did not accurately reflect the total direct care staff. Furthermore, the census was missing on multiple forms, and administrative nursing staff hours were incorrectly included as direct care hours. The facility Scheduler confirmed these discrepancies and acknowledged the errors in the staffing data.
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What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marlinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Nursing & Rehab Center | 21.5 mi | ★★★★★ | 0 | 0 |
| White Sulphur Springs Center | 28.1 mi | ★★★★★ | 20 | 1 |
| Webster Healthcare Center | 28.7 mi | ★★★★★ | 6 | 0 |
| The Woodlands Health And Rehab Center | 31.6 mi | ★★★★★ | 0 | 0 |
| Brian Center Of Alleghany | 31.8 mi | ★★★★★ | 0 | 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.