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 Seneca Trail Healthcare Center during CMS and state inspections, most recent first.
Dignity and privacy failures were identified when a resident’s suprapubic catheter urine collection bag was left uncovered and visible, another resident in the dining room was without a drink while others had beverages, and an NA was reported to have complained aloud while providing care. The resident with the catheter was cognitively intact, and the ED acknowledged the allegation involving demeaning verbal comments during ADL care.
Undercooked baked potatoes were served with the noon meal, and multiple residents on both floors stated the potatoes were too hard and not fully cooked. Several residents could not eat them, while others requested mashed potatoes instead. The DON and Dietary District Manager were notified after trays had already been delivered, and the potatoes were reported at 148 degrees F with the larger size cited as the reason they did not cook through.
Improper food storage and hand hygiene were observed in the kitchen. An opened box of frozen omelets and an opened box of frozen biscuits were left unsealed and exposed to air after breakfast prep, and an employee wiped spilled soup with gloved hands, then returned to the tray line and later touched the outside of a food service cart without changing gloves or washing hands.
Incomplete and inaccurate resident records were found for several residents. Old pneumococcal consent forms were used for residents who received or declined PCV20, enteral feeding amounts were inconsistently charted on the MAR with missing refusal documentation, a modular protein order lacked a specified amount, one resident had incorrect diagnoses and an unnecessary anticoagulant monitoring order, and another resident’s abdominal wounds were documented in a progress note but not on later skin assessments.
The facility failed to maintain an effective infection prevention and control program. Staff did not consistently follow contact and droplet precautions, including entering rooms without the PPE posted on the door, a nebulizer mask was left on a bedside table instead of being stored properly, food was handled unsafely when a tray lid fell to the floor and was placed back on the tray, and multiple wheelchairs and a geri-chair had tears, holes, cracks, and exposed padding that could not be thoroughly cleaned.
Failure to provide ADL care for dependent residents. Two residents did not receive needed bathing or nail care: one resident had documented gaps in showers and bed baths over multiple days, and another resident was observed with long fingernails and limited ROM, with OT and the DON confirming the nails needed trimming.
Failure to Honor Resident Shower Preference: A resident reported that staff did not respect her preferred shower timing and continued offering showers during the time her husband visited daily, despite her repeated requests not to be approached then. Record review showed several shower refusals documented during or around the husband’s usual visiting hours, and the DON stated the electronic task times were only documentation times, not the actual times showers were offered or refused. A nurse aide and the resident’s husband both confirmed that shower offers often occurred during the husband’s visits.
Failure to Document and Report Verbal Grievance: A resident reported missing personal items to an NA, but the grievance officer/SW was not informed and did not learn of the issue until the state agency became aware. The facility's grievance process was not working as staff were not always documenting verbal reports of grievances or concerns.
Failure to Report Allegation of Verbal Abuse: A cognitively intact resident reported that an NA complained while providing care and said she had “had enough of this place and these people.” The facility did not identify the statement as an allegation of mental abuse or report it to the appropriate state agencies, despite policy defining verbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation as abuse and requiring reporting when a resident perceives an event as abuse.
A resident’s PASARR did not include all diagnoses, with Moderate Intellectual Disabilities and Vascular Dementia with anxiety and psychotic disturbance omitted from the review. The DOSS stated the diagnoses were missed and that the PASARR would have to be redone.
A resident with an indwelling suprapubic catheter for obstructive uropathy and overactive bladder had a care plan intervention to keep the catheter bag and tubing below bladder level and provide a privacy bag. Surveyors observed the urine collection bag without a privacy cover on two occasions, with the bag visible from the room entrance and hallway, and an UM confirmed the care plan instruction had not been followed.
Missing Documentation for Daily Splint Use and Refusals: A resident with limited ROM in both hands was observed without orthotics on multiple occasions, while OT confirmed Dynaflex splints were in the resident’s closet and aides had been educated on donning them. The DON stated refusals and splint application were not being documented, and after a physician order changed the splint type, the new Dynaflex splint was not added to the TAR, leaving no record of splint use or refusal.
A resident with an order for honey thickened liquids in a Kennedy cup and a care plan identifying dehydration risk was repeatedly observed without fluids available in the room. Staff observed no drinks at the bedside, and when a drink was placed on the bedside table it was out of the resident's reach; the DON confirmed water should have been available at the bedside for aide assistance.
A resident did not receive O2 as ordered. The physician ordered O2 at 2 L via NC continuously as needed, but surveyors observed the concentrator set at 5 L/min on multiple occasions. A nurse aide confirmed the setting, and an RN later verified the order was for 2 L/min while the resident remained set at 5 L/min.
Daily staffing postings were not updated at the beginning of shifts to reflect changes in RN, LPN, and nurse aide coverage. Review of nine postings showed multiple decreases in staffing numbers, including several shifts where RN coverage dropped from one to zero and other shifts where LPN and nurse aide counts were reduced. The scheduler stated call-ins were sometimes not known until days later, and the Administrator stated the scheduler should be aware of the call-ins.
Failure to provide ordered adaptive drinking equipment. A resident had a physician order for a Kennedy cup with meals and at bedside, but staff observed a lidless coffee cup on the overbed table and the lunch tray arrived without the ordered cup. The RN confirmed the tray ticket called for the Kennedy cup and then retrieved one from the beverage cart.
The facility failed to maintain sanitary conditions in food storage and service, with unlabeled and expired items found in the kitchen and pantry. Additionally, food temperatures were not logged for several meals, and a staff member improperly handled used adaptive cups. The Culinary Director acknowledged these oversights, attributing some to a new staff member.
The facility was found deficient in waste disposal practices as the dumpster lid was observed open without staff presence, and there was no policy in place for waste management. The Administrator acknowledged the issue, and the Culinary Director confirmed the lack of a waste disposal policy.
A facility failed to correctly complete the MDS for a resident who discharged against medical advice (AMA). The discharge assessment inaccurately anticipated the resident's return, and the section on providing a reconciled medication list was incomplete. The resident left shortly after arrival, and discharge planning was not completed. An APS referral was made due to the unplanned discharge, and the DON and Administrator acknowledged the MDS coding error.
A facility failed to implement a care plan for a resident regarding education on end-of-life decisions. The resident had a DNR-CC status, and the care plan required education on the implications of discontinuing certain medical interventions. However, the facility could not provide documentation of such education, despite policy requirements for documenting treatment refusals and education provided.
A facility failed to update a resident's care plan to include non-pharmacological interventions for an anxiety disorder after discontinuing medication. Despite recommendations for interventions like music therapy and relaxation techniques, the care plan only addressed inappropriate behaviors and resistance to care. The DON acknowledged the oversight during a review.
A resident experienced significant weight loss due to the facility's failure to document enteral feeding volumes and address the issue. Despite the resident's care plan requiring monitoring of enteral intake and notifying medical providers of weight changes, the facility did not ensure these actions were taken. The dietician assumed full bolus intake without verification, and the nurse practitioner did not follow up on the resident's weight loss.
The facility inaccurately reported nurse staffing information by including administrative hours in direct care totals, contrary to CMS guidelines. Additionally, the facility failed to retain staffing posting forms for the required 18 months, as they were sent to the corporate office and disposed of. The administrator acknowledged these deficiencies.
A facility failed to accurately complete a resident's medical record, indicating ongoing occupational and physical therapy services that had been discontinued. The discrepancy was identified during a survey, and the DON and Administrator confirmed the inaccuracy.
The facility failed to maintain an effective pest control program for flies, as observed when a resident was found with a fly on her ankle. The resident complained about the persistent fly issue, which was confirmed by an LPN. The administrator attributed the problem to the nearby Virginia State Fair Grounds and their dumpsters.
Dignity and Privacy Failures
Penalty
Summary
The facility failed to honor Resident #49’s dignity and privacy related to his suprapubic catheter and urine collection bag. The facility’s Catheter Care policy provided no guidance regarding privacy covers for urine collection bags. During observation on 03/16/2026 at 3:00 PM, Resident #49’s urine collection bag did not have a privacy cover and was hanging from the bed frame. Although it was away from the door, it could be seen by people entering the room and walking around to the other side of the bed. On 03/18/2026 at 9:27 AM, the bag still did not have a privacy cover and was visible from the hallway through the slightly elevated bed, with light yellow urine visible in the bag. The Unit Manager confirmed the bag did not have a privacy cover. The facility also failed to ensure Resident #57 received a drink at the same time as other residents in the dining room. On 03/17/26 at 12:15 PM, Resident #57 was observed in the 100 hall dining room without any drink, while seven other residents at the table had drinks in front of them. RN #64 confirmed Resident #57 did not have anything to drink while the others did, and stated the resident had not yet received a drink because he was on thickened liquids and gets his drinks when his tray comes out. In a separate dignity concern, Resident #49 reported that Nurse Aide #68 complained while providing care, saying she had had enough of the place and the people. The resident was cognitively intact with a BIMS score of 15, and the Executive Director acknowledged the allegation that the aide made verbal comments out of frustration while assisting residents with ADLs.
Undercooked Baked Potatoes Served at Noon Meal
Penalty
Summary
The facility failed to ensure palatable food when baked potatoes served with the noon meal were not thoroughly cooked and were too hard for residents to eat. During a second-floor dining observation, Resident #18 and Resident #15 stated the potatoes served to them were not thoroughly cooked; both demonstrated this by sticking forks into the potatoes, and the forks did not easily go into them. Resident #15 also stated she was unable to eat the potato due to her dentures. Resident #60 similarly stated her potato was not thoroughly cooked and she was unable to eat it. Resident #13 said her potato was too hard to eat, and Resident #4 said her potato was hard but could be eaten only if cut into small pieces and covered with sour cream. Residents #38, #74, #20, and #40 in the second-floor dining room also stated they could not eat their potatoes because they had not been cooked all the way through. On the first floor, Resident #9 and Resident #73 stated their baked potatoes were undercooked and too hard to eat, and both preferred mashed potatoes instead. Resident #22 also stated her potato was not thoroughly cooked and requested mashed potatoes. Resident #37 and Resident #68 likewise requested mashed potatoes after stating their baked potatoes were not fully cooked. Resident #66 stated her potato was too hard to eat and did not want a replacement. Residents #75 and #10 were observed in their room and stated they were unable to eat their baked potatoes because they were not completely cooked and were too hard to cut. The Dietary District Manager stated the potatoes were temped at 148 degrees Fahrenheit and that she stopped the line and checked one potato before the tray carts were delivered, but the undercooked potatoes had already been sent to the floors. She also stated the larger size of the potatoes caused them not to cook completely through.
Improper Food Storage and Hand Hygiene During Meal Preparation
Penalty
Summary
The facility failed to properly store food in accordance with professional standards of practice. During the initial kitchen tour, the kitchen account manager acknowledged one opened box of frozen omelets and one opened box of frozen biscuits with the inner plastic unsealed and left open to air after breakfast prep. On a later kitchen visit, the Dietary District Manager observed unsanitary conditions during lunch preparation when Employee #112 wiped spilled soup off the counter using only her gloves and returned to the tray line without changing gloves or washing hands. In another observation, the employee walked more than 3 feet away from the tray line, touched the outside of the food service cart twice, and then returned to finish meal preparation without changing gloves or washing hands.
Incomplete and inaccurate resident records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for pneumococcal vaccination consents for four residents. The records showed that residents received or declined pneumococcal vaccines using an older consent form that referenced PCV13 or PPSV23, while the facility policy stated residents who had not received pneumococcal vaccines would be offered PCV20. The Infection Preventionist stated the old consent forms had been used for these residents and that the forms should have been for PCV20 vaccination. The facility also failed to accurately document enteral nutrition and medication orders for one resident. The resident had a physician order for bedtime enteral feeding via G-tube with Nutren 1.5, but the MAR contained multiple inconsistent entries for the amount administered, including amounts documented as 250 mls, 100 mls, 370 mls, 95 mls, 15 mls, 0 mls, 310 mls, and 191 mls. The DON stated the documentation was not accurate, could not explain several of the recorded amounts, and noted that refusals should have been documented in progress notes; however, no progress notes were present for several dates when feedings were not fully given. The same resident also had a modular protein order that did not specify the amount to be administered. In addition, the facility had inaccurate physician order documentation for another resident, including incorrect diagnoses listed for two medications and an anticoagulant monitoring order even though the resident was not taking an anticoagulant. For a third resident, the record showed abdominal wounds in a physician progress note, but subsequent skin assessments documented no skin areas noted. The resident stated she had two open areas on her stomach and said nursing was not treating them, and the DON later observed the abdominal wounds and confirmed they were not documented on the skin assessments.
Infection Control Failures With Precautions, Food Handling, and Damaged Equipment
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation, record review, and staff interviews, transmission-based precautions were not consistently followed, a nebulizer mask was not stored in a sanitary manner, food was handled in an unsanitary manner, and multiple wheelchairs and a geri-chair had damaged surfaces with holes, cracks, tears, or exposed padding that could not be thoroughly cleaned. Resident #29 was observed with a sign outside the room indicating contact precautions, including the use of gown and gloves before room entry. A nursing assistant entered the room to deliver the resident’s lunch tray without PPE. The nursing assistant stated she thought gown and gloves were only needed when providing care. Record review showed the resident had an order for enhanced barrier precautions due to a suprapubic catheter and later had an order for contact isolation related to ESBL. The DON and Infection Preventionist confirmed the resident was in contact isolation and that staff were required to wear gown and gloves when entering the room. Additional observations showed a nebulizer mask for Resident #1 lying on the bedside table rather than being stored inside the oxygen bag between treatments. In another room on droplet precautions, nursing assistants entered without the PPE listed on the door signage, including gown, N-95 mask, and eye protection, and one gown was observed open and untied. An employee delivered a lunch tray to a resident in contact isolation without mask, gown, or gloves, and another staff member picked up a lid that had fallen onto the floor and placed it back on Resident #51’s tray before delivery. Wheelchairs and a geri-chair for Residents #23, #62, #68, #14, and #51 were observed with tears, holes, cracks, broken zippers, and exposed padding, and the Infection Preventionist acknowledged the damaged equipment.
Failure to Provide ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for dependent residents. For Resident #88, record review showed that showers and bed baths were not provided during two documented timeframes in January and February 2025, including a 7-day period and a 10-day period without bathing care. The DON confirmed that showers and bed baths were not provided during those timeframes. For Resident #57, observation showed long fingernails on both hands with limited ROM, and OT #66 confirmed the resident needed nails trimmed; the DON also stated the resident's nails definitely needed cut.
Failure to Honor Resident Shower Preference
Penalty
Summary
The facility failed to honor a resident's choice regarding the timing of showers and did not facilitate her preferred schedule. Resident #49 stated that staff told her she could not get her shower because State was in the building, and she also reported that she repeatedly asked staff not to offer her a shower during the time her husband visited daily, around 4:00 PM to 5:00 PM, but staff continued to do so. During an interview on 03/19/26, the resident was in good spirits and stated she was excited and waiting for staff to take her for her shower. Record review showed multiple documented shower refusals at times that were during or around the resident's husband's usual visiting hours, including 02/23/26 at 4:31 PM, 02/26/26 at 4:56 PM, 03/05/26 at 5:25 PM, 03/09/26 at 5:18 PM, and 03/12/26 at 4:39 PM. The DON stated the electronic task record times reflected when staff documented showers given or refused, not the actual time the shower was offered or refused, and there was no log book or written sign-off sheet showing the actual offer or refusal times. A nurse aide stated it was well known that the resident's husband visited daily between 4:00 PM and 5:00 PM and that the resident had refused showers during those visits on her scheduled shower days. The resident's husband also stated staff often offered showers when he was visiting and she would refuse them.
Failure to Document and Report Verbal Grievance
Penalty
Summary
The facility failed to ensure staff documented verbal grievances from residents and shared the information with the grievance officer so prompt efforts could be made to resolve a grievance. The deficiency involved Resident #77, who was part of the sample of residents with missing personal property. The facility policy stated residents may file grievances orally, in writing, or anonymously, and that the grievance official would take immediate action to prevent further potential violations while an alleged violation was being investigated, if indicated. Resident #77 reported that several pajama tops were missing and stated she told Nurse Aide #61 about the missing items. Nurse Aide #61 confirmed she was told about the missing pajama tops. However, the Social Worker, who also served as the facility's grievance officer, stated she did not know anything was missing and did not receive information about the missing items until the state agency made her aware. The Social Worker confirmed the grievance system was not working and that staff were not always documenting verbal reports of a grievance or concern.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to identify a resident’s statement as an allegation of verbal abuse and failed to report it to the appropriate state agencies according to state law. Resident #49, who had a BIMS score of 15 indicating cognitive intactness, told surveyors that Nurse Aide #68 complained while providing care to the resident and the resident’s roommate, saying she had “had enough of this place and these people.” The facility policy defined mental abuse to include verbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation, and stated that if a resident perceives an event as abuse, the facility must report it. The Executive Director acknowledged that the resident made the allegation and that the Social Worker interviewed the resident, but stated the facility did not see psychosocial harm and therefore did not identify the incident as abuse or report it. At the time of the surveyor’s follow-up interview, Nurse Aide #68 was still working on the resident’s unit. The report also states that the facility’s abuse and neglect policy required immediate investigation when abuse was identified and that allegations of abuse must be reported to OHFLAC and APS within two hours of being reported.
PASARR Missing Diagnoses for a Resident
Penalty
Summary
The facility failed to ensure that all diagnoses were included on the Pre-admission Screening and Resident Review (PASARR) for Resident #10. A review of the PASARR dated 04/08/25 showed that the diagnoses of Moderate Intellectual Disabilities, added to the medical record on 04/08/25, and Vascular Dementia, moderate with anxiety and psychotic disturbance, added to the medical record on 02/02/26, were not included. During an interview on 03/19/2026, the Director of Social Services stated that the diagnoses must have been missed and that the PASARR would have to be redone.
Failure to Follow Catheter Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident with an indwelling suprapubic catheter related to obstructive uropathy and overactive bladder. The resident's care plan included the intervention to position the catheter bag and tubing below the level of the bladder and provide a privacy bag. During observation on 03/16/2026 at 3:00 PM, the resident's urine collection bag did not have a privacy cover and was hanging from the bed frame, visible to people entering the room and walking around to the other side of the bed. On 03/18/2026 at 9:27 AM, the urine collection bag still did not have a privacy cover and remained visible from the hallway through the slightly elevated bed, with light yellow urine observed in the bag. The Unit Manager confirmed the bag did not have a privacy cover as instructed in the comprehensive care plan.
Missing Documentation for Daily Splint Use and Refusals
Penalty
Summary
The facility failed to ensure documentation reflected that Resident #57 was given the choice on a daily basis to wear splints on both hands to maintain range of motion. Resident #57 was observed with limited ROM in both hands and no orthotics in place during multiple observations. Occupational Therapy staff confirmed Dynaflex splints were in the resident’s closet, stated aides had been educated on donning the splints, and reported the splints were rarely seen on the resident while the resident’s ROM had progressively worsened. The DON stated that refusals of splints and donning of splints were not being documented at the time. The DON also stated the splints were listed on the resident’s Kardex for daily use, but it was essentially on the honor system whether the resident was asked about the splints. Review of the last three days of progress notes showed no documented refusals, and the EMR showed splint donning had been documented on the TAR in March 2025 before a physician order changed the type of splint to Dynaflex. After that order change, the Dynaflex splint was not added to the TAR, and no documentation of splint wearing or resident refusal had been recorded since then.
Failure to Keep Fluids Available at Bedside
Penalty
Summary
Provide enough food/fluids to maintain a resident's health was not met for Resident #57, who had an order for honey thickened liquids in a Kennedy cup with meals and at bedside and was identified in the care plan as being at risk for dehydration with staff directed to assist with fluid intake as needed. The facility policy for General Hydration Services required fresh water at bedside in the proper consistency and drinking device, if appropriate. During observation on 03/16/2026, Resident #57 had no fluids available in the room for approximately three hours. On 03/17/26, the resident was observed at 10:02 AM with no drinks in the room, and at 10:18 AM a drink was placed on the bedside table at the foot of the bed, out of the resident's reach; this was confirmed by Nurse Aide #44 at 12:10 PM. Later that day at 3:31 PM, the resident was again observed in the room with no drink, and the DON later confirmed that water should have been available at the bedside for aides to assist with hydration.
Oxygen Therapy Set Above Ordered Flow Rate
Penalty
Summary
Resident #1 did not receive oxygen therapy as ordered by the physician. The physician order specified oxygen at 2 L via nasal cannula continuously as needed, but during multiple observations by surveyors the resident's oxygen concentrator was set at 5 L/min. On 03/16/26 at 1:15 PM, two surveyors observed the concentrator set at 5 L/min. A second observation on 03/17/26 at 10:14 AM again found the oxygen set at 5 L/min. At 12:20 PM on 03/17/26, Nurse Aide #68 confirmed the oxygen was still set at 5 L/min, and RN #22 later confirmed the physician order was for 2 L/min and that the resident was set at 5 L/min at 12:30 PM.
Daily Staffing Postings Not Updated
Penalty
Summary
The facility failed to update the daily staff postings at the beginning of the shifts to reflect changes in staffing numbers. During review of nine daily staff postings, all nine were found not to have been updated at the start of the shift to show staffing changes. The postings reviewed included decreases in nurse aides, LPNs, and RNs across multiple shifts, including reductions from seven to six nurse aides, four to three LPNs, three to two LPNs, and several instances where the RN count decreased from one to zero. On 03/17/26, the Nursing Staff Scheduler stated that call-ins were sometimes not known until 2 or 3 days later and that the staffing numbers were not changed at the beginning of each shift. Later that day, the Administrator stated that the scheduler should be aware of the call-ins. The facility census was 79.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
The facility failed to ensure that Resident #13 was provided adaptive eating equipment as ordered by the physician. The resident had an order written on 01/23/26 for a Kennedy cup with meals and at bedside. On 03/18/26 at 9:00 AM, the resident was observed with a plastic one-handled coffee cup on the overbed table, and the cup did not have a lid; it appeared to contain soda, with a can of soda also on the table. Later that day at 12:19 PM, RN #69 delivered the resident’s lunch tray, and the tray did not include a Kennedy cup. The resident still had the coffee cup on the overbed table. The meal tray ticket indicated the resident was to have a Kennedy cup with meals, and RN #69 confirmed this before obtaining a Kennedy cup from the beverage cart and providing it to the resident.
Sanitation and Temperature Logging Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure food was stored and served under sanitary conditions, and food temperatures were not consistently logged for three meals. During an initial tour of the kitchen, a bag of breakfast sandwiches in the walk-in freezer was found without a label or date, and a large container of an unknown beverage in the walk-in cooler was also unlabeled and undated. In the dry storage area, four bags of grits were found with expired best-by dates. Additionally, an open packet of coffee was found exposed to the air on a shelf in the floor pantry without any dates. The Culinary Director acknowledged these oversights and stated that the items would be disposed of. Furthermore, a review of the Service Line Checklist revealed that cooking and holding temperatures were not recorded for several meals, which the Culinary Director attributed to a new staff member's oversight. In the dining room, a staff member was observed handling used adaptive equipment cups without proper sanitary measures. The staff member took two used cups in her bare hand to the nutritional room for refilling, which was acknowledged by the Activities Leader. The facility's policy requires that food be prepared and served under sanitary conditions, including recording temperatures for Time/Temperature Control for Safety (TCS) items. These deficiencies indicate a failure to adhere to professional standards for food storage, preparation, and service, as well as proper handling of used items.
Improper Waste Disposal Practices
Penalty
Summary
The facility failed to ensure that trash and debris were stored in a safe and sanitary manner, as evidenced by the observation of an open dumpster lid when not in use. This deficiency was identified during an observation on September 9, 2024, at 12:43 PM, when the facility's dumpster lid was found open without any staff present. During an interview at 12:46 PM, the Administrator acknowledged the open dumpster lid and confirmed that it should have been closed, subsequently closing it after the interview. Additionally, during a separate interview at 3:55 PM, the Culinary Director reported that there was no existing policy or procedure regarding waste disposal, including the management of the dumpster.
Incorrect MDS Coding for AMA Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) record was completed correctly for a resident's discharge. During a medical record review, it was found that the MDS for a resident who discharged against medical advice (AMA) was not accurately coded. Specifically, the discharge assessment anticipated the resident's return, and the section indicating whether a reconciled medication list was provided at discharge was incomplete. The resident had discharged AMA shortly after arriving at the facility, and the discharge planning was not completed. An Adult Protective Services (APS) referral was made due to the unplanned discharge. The Director of Nursing and the Administrator acknowledged the incorrect MDS coding during an interview.
Failure to Implement End-of-Life Education Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident regarding education on end-of-life decisions. The resident, who had a history of acute hospitalization for urinary tract infection, pneumonia, and chronic obstructive pulmonary disease, had a care plan that included a Do Not Resuscitate-Comfort Care (DNR-CC) status. The care plan required the facility to provide education to the resident or their representative about end-of-life decisions, including the risks and benefits of discontinuing certain medical interventions such as weights, labs, and hospital transfers. Despite this requirement, the facility was unable to provide documentation that such education was provided. Interviews with the facility's Nurse Practitioner (NP) and administrative staff revealed that while the NP discussed the implications of the resident's heart stopping, there was no documented evidence of a comprehensive discussion about the broader implications of the resident's end-of-life care choices. The facility's policy required documentation of any treatment refusals and the education provided, but this was not adhered to in the case of this resident.
Failure to Revise Care Plan for Anxiety Disorder
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident diagnosed with an anxiety disorder. The resident, who has a history of anxiety, depression, insomnia, mood disorder, and inappropriate sexual behaviors, was seen for psychiatric services due to these behaviors. The physician recommended non-pharmacological interventions for the anxiety disorder, including offering a calm environment, music therapy, pet therapy, and other relaxing activities. However, the care plan was not updated to include these recommendations after the anxiety medication was discontinued. The care plan initially addressed the resident's sexually inappropriate behaviors and resistance to care but did not incorporate the suggested non-pharmacological interventions for anxiety. The Director of Nursing acknowledged that the care plan was resolved when the medication was discontinued but agreed that it would have been appropriate to include non-pharmacological interventions given the resident's ongoing behaviors. This oversight was identified during a medical record review and staff interview, highlighting a deficiency in the facility's care planning process.
Failure to Monitor Enteral Feeding Volume and Address Weight Loss
Penalty
Summary
The facility failed to ensure that care and services provided to a resident receiving enteral feeding were in accordance with professional standards of practice. The resident experienced significant weight loss, and the facility did not document the volume of enteral feeding administered. Despite the resident's weight loss, the nurse practitioner did not follow up on concerns regarding the resident's condition. The resident, who had a history of dysphagia and was receiving both a PO diet and enteral feedings, experienced a weight loss of over 10% within six months. The resident's care plan included monitoring the intake of enteral tube feeding and notifying the medical provider of unplanned weight changes. However, the facility failed to document the volume of enteral feed consumed, and the dietician assumed the resident was receiving the full bolus without verification. The dietician had not communicated with the physician since May, despite the ongoing weight loss. Interviews with facility staff, including the dietician and the Director of Nursing, revealed that the enteral feeding volume was not monitored as per the care plan. The nurse practitioner acknowledged the resident's weight loss but did not examine or treat the resident for this issue. The facility's policy required flush volumes to be recorded, suggesting that enteral feeding volumes should also be documented, but this was not done.
Inaccurate Nurse Staffing Information and Record Retention Failure
Penalty
Summary
The facility failed to ensure the accuracy of its daily nurse staffing information, as required by regulations. During a review of the staff posting forms, it was found that the total count of direct care nursing staff and their hours inaccurately included nursing staff with administrative duties and their administrative hours. For instance, on one occasion, the count of Registered Nurses (RNs) included hours from an RN Unit Manager, which should not have been counted as direct care hours. Similarly, Licensed Practical Nurses (LPNs) and RNs with administrative duties were incorrectly included in the direct care staff totals. The facility's administrator acknowledged that these inaccuracies were against the guidelines set by the Centers for Medicare & Medicaid Services (CMS), which require reporting based on the employee's primary role. Additionally, the facility did not retain the staffing posting forms for the required 18 months. During the survey, it was revealed that the facility did not maintain these forms, as they were sent to the corporate office for data entry and then disposed of. The facility's Medical Records representative confirmed that they were unaware of the requirement to keep these forms. The administrator also agreed that the original staffing posting forms should have been maintained, acknowledging the facility's failure to comply with this requirement.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accurate completion of a resident's medical record during the skilled documentation process. This deficiency was identified for one of the 24 residents whose medical records were reviewed during the long-term care survey. Specifically, the medical record for a resident indicated that they were receiving occupational and physical therapy services daily from August 15 to September 2. However, upon further review, it was found that these therapy services had been discontinued as of August 14 and were not included in the resident's care plan. During an interview with the Director of Nursing and the Administrator, it was confirmed that the skilled documentation was inaccurately completed, reflecting services that were no longer being provided.
Pest Control Deficiency Due to Flies
Penalty
Summary
The facility failed to maintain an effective pest control program for flies, as observed during a long-term care survey. This deficiency was identified when a resident was found lying in bed with a fly sitting on her left ankle. The resident expressed that flies were a persistent issue in the facility. An LPN confirmed the presence of the fly, noting that it continued to land on the resident's leg. The facility's administrator acknowledged the problem, attributing it to the proximity of the Virginia State Fair Grounds and their dumpsters, which are located along the property line behind the facility.
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.
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What surveyors actually found near you
We read the 95 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lewisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lewisburg Healthcare Center | 1.2 mi | ★★★★★ | 11 | 1 |
| White Sulphur Springs Center | 12 mi | ★★★★★ | 20 | 1 |
| Summers Healthcare Center | 19.7 mi | ★★★★★ | 27 | 1 |
| Rainelle Healthcare Center | 21.1 mi | ★★★★★ | 6 | 0 |
| Lindside Healthcare Center | 23.1 mi | ★★★★★ | 24 | 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.