Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Raleigh Center during CMS and state inspections, most recent first.
Unclean room fixtures and improper closet storage. Surveyors observed dust buildup on air vent filters in two residents’ rooms, and in another resident’s room the closet door would not close and a plastic bag with items was hanging out. The DON confirmed the closet condition and the resident gave permission for the closet to be straightened.
Menu and recipe noncompliance led to residents receiving foods that did not match the menu or tray tickets. A resident was served plain angel food cake with carrots instead of carrot cake and white bread instead of wheat bread, and the menu substitution log did not document those changes. Two residents on a pureed diet were given vanilla pudding instead of the listed key lime pie, and the HCSG DM confirmed pudding was served in place of the pureed dessert.
A surveyor test tray found food served at improper temperatures and not prepared as menued: cold items were above the required temp, pasta salad was not chilled per recipe, and an egg salad sandwich was served on white bread instead of wheat. The advanced consistency meal was bland, thick, and unappealing, and staff said key recipe ingredients were missing or substituted. Multiple residents also reported the food was bad, awful, bland, or missing items.
Food Storage and Kitchen Sanitation Deficiencies: Surveyors observed multiple food safety and sanitation issues, including unlabeled and expired food items, improperly dated opened products, and soiled kitchen equipment and surfaces. Findings included debris in the freezer, water pooling in the walk-in refrigerator, food splatter in the microwave, dusty knife racks, unclean crumb trays, and outdated items in the nourishment room refrigerator. The DDS and HCSG DM acknowledged the concerns during the kitchen walkthroughs.
Improper Storage and Disposal of Garbage and Refuse: Surveyors observed multiple trash cans in the kitchen and dish room that were not in constant use and lacked lids, and a trash can by the hand washing sink that was soiled on the outside. On a follow-up visit, the kitchen trash can still had its lid off, and the trash can by the hand washing sink still needed cleaning and had no liner with debris/trash inside.
Infection prevention practices were not followed during meal service and contact precautions. An ice scoop remained in the ice storage container while residents were served, several residents did not receive hand hygiene when entering or returning to the dining room, and a DON was observed using hand sanitizer after exiting a room for a resident on contact precautions for C-diff instead of soap and water.
A resident with schizoaffective disorder, bipolar type had Bipolar Disorder omitted from Section I on three MDS assessments. The medical record showed the diagnosis was active, but the MDSs did not mark it as an active diagnosis, and the NHA acknowledged the error.
Failure to provide ordered adaptive dining equipment occurred for a resident with hemiplegia and legal blindness. The resident’s care plan and meal ticket specified a plate guard and built up utensils with meals, but an observation found the plate guard missing from the meal tray. The Administrator confirmed the plate guard was ordered and that the care plan was not implemented.
A resident’s care plan was not revised after a protein supplement was discontinued. The resident had significant wt. loss, average PO intake of 65%, obesity by BMI, a hx of Ozempic not currently ordered, and recent diuretic reordering with possible wt. fluctuations. The nutrition assessment noted refusal of most modular protein and recommended discontinuing it, but the care plan still listed the supplement as ordered. The DON confirmed the nutritional portion of the care plan was missed.
Failure to provide ordered plate guard. A resident with hemiplegia and legal blindness had an order for a regular diet with plate guard and built-up utensils, but the plate guard was missing from the meal tray during observation. The diet ticket listed the plate guard, and the Administrator confirmed it was supposed to be provided.
A resident's POST form was left unsigned by the POA, despite verbal consent being obtained and no documentation in the EMR showing the form had been mailed or that follow-up had been attempted before surveyor intervention. The SW later confirmed the missing signature and stated the POA said she would mail it.
A medicine cart was left unlocked and unattended by an LPN during a med pass, creating an accident hazard. The LPN acknowledged the oversight upon returning to the cart, and the administrator confirmed that the cart should have been locked when not in direct view. This situation had the potential to impact multiple residents in the facility.
Surveyors identified deficiencies in food storage and sanitation, including food items stored on the floor, serving pans and bowls stacked while still wet, and an unclean oven with visible debris and grease. Dietary staff confirmed these conditions during interviews.
The facility failed to maintain a homelike environment by not removing meal trays after service and storing trash bags on hand towel racks in residents' rooms. The ADON and Administrator acknowledged the oversight regarding meal trays, while an LPN confirmed the inappropriate storage of trash bags, which were kept for staff use.
A facility failed to protect residents from abuse and neglect, as a NA neglected duties by ignoring call lights and using her phone, leading to an RN covering her responsibilities. A resident waited over an hour for food due to communication failures. Another resident with a history of aggression was involved in altercations, but the facility did not implement effective interventions or report incidents, as acknowledged by the DON.
The facility was found to have deficiencies in safety and medication management. A resident struggled to maneuver his wheelchair over fall mats, and oxygen tanks were improperly stored without signage. Additionally, medication carts were left unlocked with medications unsecured, and a nurse was unable to identify a resident's medication. These issues were acknowledged by staff and had the potential to affect multiple residents.
The facility failed to provide nighttime snacks to residents as required. Snacks were left undelivered at the nurses' station, affecting multiple residents. Staff confirmed they did not distribute the snacks, and residents reported not receiving them. The facility's policy requires snacks to be offered within 15 minutes of delivery, but this was not followed.
The facility failed to maintain sanitary food storage and handling practices. An expired jar of apple sauce was found in use, and the ADON was observed assisting a resident without sanitizing hands before handling a clean tray. Additionally, a refused meal tray was improperly returned to the food delivery cart, risking cross-contamination.
A resident reported delays in call light response and restrictions on mobility after using the bedpan, feeling punished for needing assistance. Despite her care plan emphasizing physical activity, staff reportedly told her it was against the rules to get back up after being placed in bed. The DON was unaware of these issues.
A resident's call light was improperly positioned, making it inaccessible due to her inability to use her left hand. An LPN acknowledged the issue and repositioned the call light. The DON and Nurse Educator confirmed the resident's dependency with upper extremities and lack of documentation or care planning for her condition.
A facility failed to implement its Abuse Prohibition policy, leading to multiple incidents involving a resident with aggressive behavior. Despite documented aggressive actions towards other residents, the facility did not take adequate steps to prevent further incidents or provide sufficient supervision. The facility also failed to report allegations of abuse within the required timeframe, contributing to the deficiency identified by surveyors.
A resident with a history of aggressive behavior was involved in multiple altercations with other residents, including pulling hair and hitting. Despite these incidents, the facility failed to report and investigate the allegations of abuse as required by their policy. The DON acknowledged the lack of intervention and documentation, and the facility's social worker confirmed no investigation was conducted for one incident.
A facility failed to investigate an alleged violation involving a resident's fracture, as statements from all relevant staff, including an NA involved in the resident's care, were not obtained. The resident's care plan required two-person assistance for bed mobility and toileting, but documentation showed only one-person assistance was provided on multiple occasions. The facility did not review documentation that could have identified the risk for accidents.
A facility failed to accurately complete an MDS for a resident discharged home. The nursing notes and discharge plan indicated a home discharge, but the MDS incorrectly recorded a discharge to a short-term hospital. The DON confirmed the error during an interview.
A facility failed to create an individualized care plan for a resident with depression, despite having a physician's order for Escitalopram. The care plan lacked specific measures to address the resident's depression, a deficiency confirmed by the DON during an interview.
The facility failed to follow physician orders for a resident who was observed without a required protective helmet while out of bed, despite having a history of brain surgery. Additionally, another resident with bipolar disorder reported receiving medications late, which was confirmed by the DON. These deficiencies highlight lapses in adhering to care plans and medication schedules.
A facility failed to timely act on a Medication Regimen Review (MRR) for a high-risk medication for a resident with multiple diagnoses, including anxiety and dementia. The MRR recommended a review of Buspar dosage, but the facility did not address it within the required 30 days, delaying action until a psychiatrist's visit months later. This oversight was acknowledged by the facility's Infection Preventionist, indicating a deficiency in medication management.
Two residents were served incorrect diets when bologna sandwiches were provided instead of the required Peanut Butter and Jelly sandwiches. The Dietary District Manager confirmed that both residents needed ground meat, which was not provided. Meal tickets verified the dietary errors.
The facility failed to properly dispose of garbage and refuse, as observed during a tour. The dumpster was found open with debris, including food particles, trash, gloves, and masks scattered around it. A housekeeper and the DON acknowledged the condition of the dumpster and the surrounding area.
The facility failed to maintain accurate medical records for two residents. One resident's blood pressure was incorrectly documented as being taken from a prohibited arm, despite her refusal and medical orders against it. Another resident was receiving medication for depression without a corresponding diagnosis in the records. The DON acknowledged these documentation errors.
Unclean Room Fixtures and Improper Closet Storage
Penalty
Summary
The facility failed to maintain a safe, clean, homelike environment for three of 26 residents reviewed. In Resident #3's room, surveyors observed the air vent filters in the air conditioner/heating unit with a dust film approximately one quarter of an inch thick attached to the filter. In Resident #13's room, surveyors made the same observation of the air vent filters, with a dust film approximately one quarter of an inch thick attached to the filter. In Resident #25's room, the closet door was observed to be open with a plastic bag containing items hanging out and the door would not close; this condition was still present on a later observation, and the DON confirmed the door would not close and that items were hanging out in the bag.
Menu and Recipe Noncompliance
Penalty
Summary
The facility failed to meet residents’ nutritional needs in accordance with established national guidelines because menus, recipes, and meal preparation were not followed as planned. The cited policy stated that menus are to be planned in advance, developed using an approved menu planning guide, include standardized recipes, and have a menu substitution log maintained on file. Surveyors found that the facility did not follow the menu or recipes and did not prep in advance, affecting more than a limited number of residents who received meals from the kitchen. For Resident #11, on 03/16/26 the resident was served a piece of plain unfrosted angel food cake sitting on top of finely chopped and grated fresh carrots instead of the carrot cake listed on the menu and tray ticket, and staff verified that the cake did not look like traditional carrot cake. On 03/17/26, the same resident received white bread instead of the wheat bread listed for an egg salad sandwich on the menu, recipe, and tray ticket, and staff verified the bread mismatch. The HCSG District Manager later provided a carrot cake recipe and menu substitution log, but the recipe did not match what residents received and the substitution log did not include the cake substitution or the bread substitution. Resident #30 and Resident #63, both on a pureed diet, were served vanilla pudding instead of the key lime pie listed on the lunch menu and tray ticket; when the administrator asked for a serving of pureed key lime pie, the HCSG DM provided vanilla pudding and stated that vanilla pudding had been served to the pureed diets instead of pureed key lime pie.
Food Served at Improper Temperatures and Not Prepared as Menued
Penalty
Summary
The facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature, including failure to serve cold foods cold. During a surveyor test tray review on 03/17/2026, the Healthcare Services Group District Manager brought a freshly made tray to the dining room and took temperatures of the items. The egg salad sandwich measured 50 degrees Fahrenheit, baked potato soup measured 157 degrees Fahrenheit, pasta salad measured 57 degrees Fahrenheit, and sliced peaches measured 40 degrees Fahrenheit. The pasta salad did not meet the point-of-service maximum temperature regulation for cold foods of 50 degrees Fahrenheit. The District Manager stated the pasta salad had been cooked that day and chilled for forty-five minutes, while the recipe required the pasta to be chilled to 41 degrees Fahrenheit before adding vegetables and dressing, then chilled another 2 to 3 hours before serving. The survey team also found the advanced consistency meal was not prepared as expected. The baked potato soup was described as bland and thick and chunky rather than soup-like, the pasta salad was visually unappealing and appeared to be pasta only, smelled and tasted like white vinegar, and the egg salad sandwich was served on white bread instead of the wheat bread listed on the menu. The District Manager and Administrator stated that there were not enough green onions for the soup recipe, that some green onions were used, that the facility made its own Italian dressing instead of using the bulk Italian dressing called for in the recipe, and that fresh parsley for the pasta salad was not available. Resident interviews also reflected dissatisfaction with the food, with multiple residents describing it as bad, awful, bland, or missing items that were supposed to be included.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, and failed to follow proper sanitation practices for the kitchen and food preparation equipment. During a kitchen walkthrough, surveyors observed one container of rice with no label or date in the storage room, one container of maraschino cherries that had expired, and one opened package of brussels sprouts in the freezer that was not dated. They also observed debris on the freezer floor, water pooling on the walk-in refrigerator floor, debris on two convection ovens, dusty knife racks, food splatter on the inside top of the microwave, a toaster crumb tray needing cleaning, clean cups and bowls not stored upside down above the coffee maker, debris and dust on food scoop holding racks, and four spices not closed tightly. In the nourishment room refrigerator, surveyors found one bottle of balsamic dressing without an open or use-by date and seven bowls of applesauce that were outdated with use-by dates of 3/10/26 and 3/15/26. On a second visit to the kitchen, surveyors observed the bottom of the reach-in refrigerator was soiled and needed cleaning, and the floor behind and underneath the milk cooler, stove, steamer, and oven was soiled and needed cleaning. The Director of Dining Services and the District Manager for Healthcare Services Group acknowledged the concerns during the observations.
Improper Storage and Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to store and dispose of garbage and refuse properly in the kitchen and dish room. During an initial walkthrough on 03/16/2026, surveyors observed two trash cans in the kitchen that were not in constant use and did not have lids, the trash can in the dish room was not in constant use and also lacked a lid, and the trash can located by the hand washing sink was soiled on the outside. On a second visit to the kitchen on 03/17/26, surveyors again observed that the kitchen trash can not in constant use had its lid off, the outside of the trash can beside the hand washing sink still needed to be cleaned, and there was no liner in that trash can with debris/trash inside of it.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections. During dining room observation, the ice scoop remained in the ice storage container while residents were being served, and staff confirmed that it was not being placed in a separate holder after each use. The scoop was observed in the ice storage container on both B Hall and A Hall during meal service, and the Administrator and Admissions Director confirmed the practice. During the same dining room observation, residents were not observed receiving hand hygiene before the meal or when returning to the dining room. One resident was brought into the dining room after the initial hand hygiene process and did not receive hand hygiene before being given drinks and a meal. Two other residents left the dining room and later returned, including one who rolled her wheelchair through the dining room and hallway before returning, and no hand hygiene was performed upon their return. In addition, a resident in contact precautions for C-diff had a contact precaution sign posted, PPE available at the doorway, and an active order for contact precautions while receiving vancomycin for suspected C-diff; however, the DON was observed exiting the room and using hand sanitizer, and the surveyor and Administrator confirmed that soap and water should be used for C-diff.
MDS Did Not Accurately Reflect Active Bipolar Diagnosis
Penalty
Summary
The facility failed to accurately record an active diagnosis on Resident #12’s MDS. The resident’s medical record showed an active diagnosis of schizoaffective disorder, bipolar type, with an onset date of 05/17/24. However, the resident’s most recent MDS completed on 12/31/25 did not mark Bipolar Disorder in Section I for Active Diagnoses. A review of the MDS completed on 09/22/25 also found that Bipolar Disorder was not marked, and the MDS completed on 07/23/25 likewise did not mark Bipolar Disorder. This discrepancy was reviewed with the Nursing Home Administrator on 03/19/26 at 12:10 PM, and she acknowledged the error on all three MDSs.
Failure to Provide Ordered Adaptive Dining Equipment
Penalty
Summary
Failure to implement a personalized care plan for adaptive dining equipment was identified for Resident #26. The resident had diagnoses including hemiplegia affecting the left non-dominant side and legal blindness, and had an order for a regular/liberalized diet, regular texture, standard thin liquids, plate guard, built up utensils with meals, no salt packet, and sugar substitute. The care plan also included interventions to provide a plate guard and built up utensils with meals as ordered. On 3/16/26 at 12:20 PM, an observation found Resident #26 did not have a plate guard with the noon meal. The diet ticket for the meal listed built up foam utensils and a plate guard, but the plate guard was not on the tray. On 3/26/26 at 12:23 PM, the Administrator confirmed the resident was supposed to have a plate guard and that it was missing from the meal tray. On 3/26/26 at 1:10 PM, the Administrator confirmed the care plan was not implemented in this case.
Care Plan Not Updated After Nutritional Supplement Discontinued
Penalty
Summary
The facility failed to ensure a care plan was revised and updated when a nutritional supplement was discontinued for Resident #2. The resident’s nutrition assessment noted significant change and weight review, average oral intake of 65% meeting about 90% of estimated needs, significant weight loss over 30 and 180 days, a desired goal weight of 150 pounds, a history of Ozempic not currently ordered, and recent reordering of a diuretic with possible weight fluctuations. The assessment also stated the resident had obesity by BMI, was on a therapeutic diet due to modular protein three times daily, and was refusing most of the modular protein, with a recommendation to discontinue it due to refusals. The care plan still listed protein supplement as ordered, and the resident’s order showed protein liquid twice daily, 1 ounce, with the supplement discontinued on 7/26/25. The DON confirmed the care plan was not revised to reflect the discontinued supplement and stated the nutritional part had been missed.
Failure to Provide Ordered Plate Guard
Penalty
Summary
The facility failed to provide adaptive eating equipment for Resident #26 as ordered. Resident #26, who has diagnoses including hemiplegia affecting the left non-dominant side and legal blindness, had an order for a regular/liberalized diet with regular texture, standard thin liquids, plate guard, and built-up utensils with meals. During observation on 3/16/26 at 12:20 PM, Resident #26 did not have a plate guard with her noon meal. The diet ticket on the tray listed built-up foam utensils and a plate guard, but the plate guard was not present. On 03/26/26 at 12:23 PM, the Administrator confirmed the resident was supposed to have a plate guard, that it was on the meal ticket, and that it was missing from the tray.
Unsigned POST Form Missing POA Signature
Penalty
Summary
The facility failed to ensure a resident's Physician Orders for Scope of Treatment (POST) form was signed by the resident's POA. During record review, the POST form showed verbal consent obtained from the POA, but there was no signed POST form in the electronic medical record. The state surveyor requested documentation showing that the form had been mailed for signature or that follow-up had been attempted, but no such documentation or records were available until surveyor intervention. The Social Worker later confirmed that the POST form still had no signature and stated that follow-up had been done and the POA said she would mail it. Resident #39 was one of three residents reviewed for advance directives.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medicine cart was left unlocked and unattended during a medication pass. An LPN was observed preparing medication at the cart and then entered a resident's room, leaving the cart unsecured. Upon returning, the LPN acknowledged that the cart had been left unlocked. The facility administrator confirmed that the medication cart should have been locked when not in the nurse's direct line of sight. This incident presented an accident hazard and had the potential to affect more than a limited number of residents in the facility, which had a census of 65 at the time.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and serving practices. Specifically, a case of oats and a case of grits were found sitting directly on the floor in the dry stock room, both dated for recent delivery. Additionally, five trays with blue serving bowls were found near the food plating area while still wet, and further inspection revealed that large, medium, and small pans used for serving food were also stacked while wet, with water running off the pans onto the floor. These observations were confirmed by dietary staff present at the time. Further inspection of the facility's cook range and ovens revealed that the bottom right oven contained crumbs, burnt substances, and a dried white/yellow substance resembling old grease drippings. Dietary staff interviewed stated that the bottom ovens were not in use and were unsure how they became soiled. These findings indicate that food was not being stored, prepared, or served in accordance with professional standards, as required.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for its residents, as observed during a meal tray service and a tour of Unit B. During the meal service, trays were placed on tables for residents but were not removed afterward, contrary to the facility's policy. This was acknowledged by both the Assistant Director of Nursing and the Administrator, who confirmed that the trays should have been removed according to the policy titled NSG270 Meal Service. Additionally, during a tour of Unit B, it was observed that trash bags were stored on the hand towel racks in residents' rooms, alongside clean towels and washcloths. This practice was confirmed by an LPN, who stated that the staff stored the trash bags there for personal use, acknowledging that it did not create a homelike environment for the residents. These deficiencies were noted to have the potential to affect a limited number of residents within the facility, which had a census of 63 at the time.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by several incidents involving staff and residents. A Nurse Aide (NA) was observed neglecting her duties by ignoring call lights and using her cell phone during her shift. This neglect resulted in a Registered Nurse (RN) having to leave her medication cart to answer a call light in the NA's assigned area. The NA was also observed taking an unauthorized smoke break, further neglecting her responsibilities. Resident #2 experienced neglect when she requested food after missing lunch, and her request was not communicated to the kitchen staff in a timely manner. Despite the Licensed Practical Nurse (LPN) acknowledging the request, the Dietary Manager confirmed that no request had been made. As a result, Resident #2 waited over an hour and twenty minutes before receiving her meal, highlighting a breakdown in communication and care delivery. Resident #16, who has a history of aggressive behavior and multiple psychiatric diagnoses, was involved in several altercations with other residents. Despite documented incidents of aggression, including hitting and pulling hair, the facility failed to implement effective interventions or report the incidents as required by their abuse prohibition policy. The Director of Nursing (DON) acknowledged the lack of documentation and reporting for these incidents, indicating a failure to follow established procedures to protect residents from abuse.
Deficiencies in Safety and Medication Management
Penalty
Summary
The facility was found to have several deficiencies related to accident hazards and inadequate supervision. During a tour, a resident was observed struggling to maneuver his wheelchair over fall mats placed around his bed, which impeded his ability to safely access his side of the room. The Licensed Practical Nurse (LPN) acknowledged that the mats should be removed when residents are out of bed, indicating a lapse in ensuring a hazard-free environment. Additionally, oxygen tanks were found unattended in a resident sitting area without proper signage, posing a potential safety risk. The Registered Nurse (RN) confirmed that the oxygen tanks should not have been stored there and removed them upon discovery. Further deficiencies were noted in the storage of medications. During facility tours, medication carts were found unlocked with keys in the locks, and medications were left unsecured on top of the carts. In one instance, a nurse was unable to identify the resident to whom a medication belonged, highlighting a lack of proper medication management. The Director of Nursing acknowledged that the medication carts should have been locked and medications securely stored, as per the facility's policy. These lapses in medication storage and environmental safety had the potential to affect more than a limited number of residents in the facility.
Failure to Provide Nighttime Snacks to Residents
Penalty
Summary
The facility failed to provide snacks to residents who wished to receive them at night, as observed during a survey. Multiple residents, including Resident #24, #28, #33, #51, #52, #22, and #58, were affected by this deficiency. The snacks, which were supposed to be delivered during the third shift, were found undelivered and left at the nurses' station. Interviews with the District Dietary Manager and the Dietary Manager confirmed that the snacks were not passed to the residents as required. The Dietary Manager noted that the last dietary employee leaves at 7:00 PM, and the snacks are left at the nurses' station, where they often remain untouched until the next day. Nurse Aides #15 and #33 confirmed that they had not offered the snacks to residents during their shifts. They admitted that the snacks were left at the nurses' station and were not distributed to the residents. Resident #28 expressed disappointment at not receiving the snack, stating that they would have liked to have it but were unaware of its availability. Similarly, Resident #52 reported that they rarely received snacks before bed, estimating that it happened less than once every two weeks. The facility's policy for meal and snacks requires that evening snacks be offered to every resident, with snacks being passed within 15 minutes of delivery to the unit. However, the Director of Nursing acknowledged that the facility had not been following these procedures. Resident Council members, including Residents #22 and #58, also reported that snacks were not consistently offered at bedtime, with staff often leaving them at the nurses' station instead of distributing them to residents.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a sanitary manner, as observed during a kitchen tour and dining observations. During a kitchen tour, a jar of apple sauce with a discard date of 7/19/24 was found in the reach-in refrigerator and was still in use. This was acknowledged by a staff member and later by the Dietary Manager during an interview. This oversight indicates a lapse in monitoring and adhering to food safety protocols regarding the storage and use of expired food items. Additionally, during dining observations, the Assistant Director of Nursing (ADON) was seen assisting a resident with eating and then handling a clean tray without sanitizing her hands, which poses a risk of cross-contamination. Furthermore, the ADON placed a refused meal tray back into the food delivery cart with other trays that had not yet been served, which she acknowledged could lead to cross-contamination. The Administrator confirmed that the tray should not have been returned to the cart, indicating a breach in proper food handling procedures.
Resident Dignity Compromised by Delayed Response and Mobility Restrictions
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity, as evidenced by the experiences of a resident who reported delays in response to her call light and restrictions on her mobility after using the bedpan. The resident, who is blind and requires a lift for transfers, reported that staff often took up to 20 minutes to respond to her call light. She also stated that after using the bedpan, she was not allowed to get out of bed for the rest of the day, which made her feel as though she was being punished for needing to use the bathroom. This was corroborated by her private caregiver, who reported hearing a nurse aide suggest that the resident use her brief instead of being transferred back to bed. The resident's care plan indicated that she was at risk for falls and required assistance with transfers using a full-body sling. The care plan also emphasized the importance of maximizing physical activity to enhance muscle tone and mobility. Despite this, the resident reported being told that it was against the rules to get back up after being placed in bed. The Director of Nursing was unaware of these issues and had not received any complaints from the resident prior to the surveyor's report.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was positioned in a manner that allowed her to use it effectively, which was identified during a long-term care survey. The resident, who was unable to use her left hand, was found with her call light clipped to the left side of her bed, making it inaccessible. This issue was observed when a Licensed Practical Nurse (LPN) entered the room and acknowledged the call light was on the non-dominant side, subsequently moving it to the resident's right side. The Director of Nursing (DON) and Nurse Educator later confirmed that the resident's minimum data set (MDS) indicated dependency with upper extremities, and there was no documentation from a physician addressing the resident's inability to use her left hand. Despite the resident working with physical therapy to strengthen her left hand, the deficiency was noted due to the lack of care planning and diagnosis for her condition.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy, resulting in multiple incidents involving Resident #16, who has a history of aggressive behavior. Resident #16, diagnosed with various mental health disorders including schizoaffective disorder and dementia, exhibited aggressive behavior towards other residents, including pulling hair and hitting. Despite these behaviors being documented in progress notes and the electronic medication administration record, the facility did not take adequate steps to prevent further incidents or provide sufficient supervision. On several occasions, Resident #16 was involved in altercations with other residents, including an incident where she hit her roommate, Resident #24, during a surveyor's observation. The facility's policy required that any patient who threatened or attacked another be removed from the situation and that an investigation be conducted. However, the Director of Nursing (DON) admitted that no interventions, such as room changes, were implemented due to the family's wishes, and there was a lack of documentation and investigation for some incidents. The facility also failed to report allegations of abuse within the required two-hour timeframe, as mandated by their policy and state regulations. The DON acknowledged that the facility did not follow the Abuse Prohibition policy, and the Social Worker confirmed that no investigation or report was made for a specific incident. This lack of adherence to policy and failure to document and report incidents contributed to the deficiency identified by the surveyors.
Failure to Report and Investigate Resident Aggression
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #16, who has a history of aggressive behavior towards staff and other residents. Resident #16 has multiple diagnoses, including schizoaffective disorder, bipolar type, and vascular dementia with behavioral disturbance, and is on several medications. The resident's care plan includes interventions for managing cognitive and mood symptoms, but there were several documented incidents of aggressive behavior, including pulling another resident's hair and hitting a roommate. Despite these incidents, the facility did not follow its policy on abuse prohibition, which requires reporting allegations of abuse within two hours. The Director of Nursing (DON) acknowledged that no intervention was put in place to prevent further altercations between Resident #16 and other residents, citing the family's wishes not to separate Resident #16 from her roommate. The DON also admitted that there was no investigation or documentation for certain incidents, and the facility's social worker confirmed that an investigation was not conducted for one of the incidents. The surveyor observed an altercation where Resident #16 hit her roommate, Resident #24, during a tray pass for lunch. Nurse aides intervened to separate the residents, but the facility's failure to report and investigate previous incidents contributed to the ongoing risk of harm. The DON was unable to provide documentation for several incidents and acknowledged that the facility's abuse prohibition policy was not followed.
Failure to Investigate Alleged Violation and Provide Correct Level of Care
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation involving a resident who sustained a moderately displaced impaction fracture of the distal femur metaphysis. The investigation did not include statements from all relevant staff members, particularly Nursing Assistant (NA) #63, who was involved in the resident's care during the time leading up to the incident. The facility was unable to determine the origin of the injury, and the investigation did not adequately review the level of care provided to the resident, which was documented as requiring extensive assistance from two persons for bed mobility and toileting. The facility's documentation revealed that the resident received only one-person assistance for these tasks on multiple occasions, contrary to the care plan requirements. This discrepancy was not identified or addressed during the investigation. The Director of Nursing (DON), Nurse Practice Educator (NPE) #34, and Social Worker (SW) #61 acknowledged that they did not review the facility's Documentation Survey Report for assisted daily living tasks, which could have highlighted the risk for accidents. NA #63, who was involved in providing incorrect assistance, was not interviewed as part of the investigation, and had not returned to the facility since the incident.
Inaccurate MDS Completion for Discharged Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for a resident who was discharged home. During a medical record review, it was found that the nursing notes and discharge plan documentation indicated the resident was discharged home, with their belongings packed and medications discussed. However, the MDS inaccurately recorded that the resident was discharged to a short-term general hospital. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the incorrect coding on the MDS.
Failure to Develop Comprehensive Care Plan for Depression
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan for a resident diagnosed with depression. During a medical record review, it was found that the resident had a physician's order for Escitalopram Oxalate Tablet 20 MG to be administered for depression. However, the resident's care plan did not include a specific plan addressing this diagnosis. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the comprehensive care plan for depression had not been developed for the resident.
Failure to Follow Physician Orders and Medication Administration Times
Penalty
Summary
The facility failed to provide care according to physician orders for Resident #15, who had multiple diagnoses including hemiplegia, epilepsy, cerebral palsy, and a history of traumatic brain injury. The resident had a physician's order to wear a protective helmet when out of bed to prevent injury due to a previous brain surgery. However, observations on multiple occasions revealed that the resident was out of bed in a geri-chair without the helmet. An LPN acknowledged the oversight, mistakenly believing the order had been discontinued, but confirmed it was still active. Additionally, the facility did not administer medications on time for Resident #25, who has a diagnosis of bipolar disorder and reported difficulty sleeping if evening medications are delayed. The resident's medications, including Tamsulosin and Depakote, were documented as being administered several hours late on specific dates. The Director of Nursing confirmed the late administration of these medications, acknowledging the failure to adhere to the scheduled times.
Failure to Timely Act on Medication Regimen Review
Penalty
Summary
The facility failed to timely act upon a Medication Regimen Review (MRR) for a high-risk medication for one of the residents reviewed during the Long-Term Care Survey Process. The resident, identified as Resident #16, had multiple diagnoses including anxiety disorder, insomnia, major depressive disorder, schizoaffective disorder, psychotic disorder with hallucinations, unspecified dementia, Alzheimer's disease, and vascular dementia with behavioral disturbance. The resident was receiving several medications, including Clonazepam, Cymbalta, Nuplaid, and Remeron. A recommendation from an MRR dated January 17, 2024, suggested a review of the current dose of Buspar for a gradual dose reduction, as per CMS regulations. The facility's policy required acting upon pharmacy recommendations within 30 calendar days. However, the recommendation from the MRR was not addressed until a psychiatrist's visit on May 17, 2024, which was well beyond the 30-day requirement. During interviews, the facility's Infection Preventionist acknowledged the delay, indicating that the facility had not acted upon the recommendation in a timely manner, contrary to their policy. This oversight was identified during a record review and staff interview, highlighting a deficiency in the facility's medication management process.
Incorrect Diets Served to Two Residents
Penalty
Summary
The facility failed to provide the correct diet to two residents, identified as Resident #24 and Resident #28, as observed during a tour of the nourishment room. At approximately 10:15 AM, two bologna sandwiches were found labeled for these residents, although the labels indicated they should have received Peanut Butter and Jelly sandwiches. The dietary needs for both residents required ground meat, as confirmed by the Dietary District Manager (DDM) during an interview. The DDM verified that neither resident should have received a bologna sandwich unless the meat was chopped. Upon reviewing the meal tickets, it was confirmed that the wrong diets were served, with Resident #24 requiring a Regular/Liberalized-Advanced diet with ground meat and Resident #28 requiring a Consistent Carbohydrate-Advanced diet with ground meat.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a tour at approximately 10:00 AM on August 25, 2024. The dumpster was found with its lid and door open, surrounded by debris including food particles and trash scattered on the ground. Additionally, gloves and masks were observed lying around the dumpster area. Housekeeper #88 acknowledged the condition of the dumpster and the surrounding area, and the Director of Nursing (DON) also confirmed the state of the dumpster upon arrival at the facility.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to accurately maintain medical records for two residents, leading to deficiencies in documentation. For one resident, the facility incorrectly documented blood pressure readings taken from the left arm, despite medical orders prohibiting this due to the presence of a fistula. The resident, who is cognitively intact with a BIMS score of 15, confirmed that she does not allow blood pressure measurements on her left arm, indicating that the documentation errors were not due to actual practice but rather incorrect record-keeping. The Director of Nursing acknowledged these errors and stated that the facility was auditing the notes and documentation. For another resident, the facility's medical records showed a discrepancy between the physician's orders and the documented diagnoses. The resident was receiving medication for depression, yet there was no corresponding diagnosis of depression listed in the medical records. The Director of Nursing confirmed this inconsistency and agreed that the diagnosis was missing from the records, indicating a lapse in ensuring accurate and complete medical documentation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 119 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Daniels
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Beckley | 4.3 mi | ★★★★★ | 7 | 0 |
| Pine Lodge | 5.3 mi | ★★★★★ | 17 | 0 |
| Beckley Healthcare Center | 7.4 mi | ★★★★★ | 21 | 0 |
| Main Street Care | 13.5 mi | ★★★★★ | 7 | 0 |
| Hilltop Center | 13.7 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.