Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Summers Healthcare Center during CMS and state inspections, most recent first.
A resident with orders for honey-thick liquids was observed receiving a bedside drink that did not appear to meet the required moderately thick consistency. Staff gave conflicting instructions on how much thickener to use, with one LPN adding three pumps to 8 oz of water and the Unit Manager incorrectly referencing spoon-thick directions. The resident had recently been hospitalized for septic shock, acute/chronic hypoxic respiratory failure, and aspiration pneumonia, and the facility also had no honey-like pre-thickened liquids available in the nourishment pantry refrigerator.
Multiple residents experienced harm due to the facility's failure to recognize and treat changes in condition, follow physician orders for medication administration and monitoring, and ensure dietary safety. Errors included missed side effect monitoring, improper medication administration, lack of documentation, and failure to protect a resident with an NPO order from receiving food, resulting in hospitalization and death.
Staff failed to properly assess, monitor, and treat pain for three residents, including not providing ordered interventions, not notifying the physician of uncontrolled pain, not investigating the cause of increased pain that was later found to be due to fractures, and not ensuring timely pain relief when a prescribed medication was unavailable. These failures resulted in actual harm and were confirmed through record review and interviews.
The facility did not provide a dignified dining experience by serving meals with plastic silverware to most residents due to a shortage of clean utensils. Additionally, a nurse aide entered a resident's room without knocking or announcing, contrary to facility policy, resulting in a failure to maintain resident privacy and dignity.
The facility did not consistently follow posted menus or provide residents with the foods they ordered, resulting in menu substitutions, missing items, and meals not prepared according to recipes. A resident did not receive the double fruit portions or ice cream indicated on his tray ticket, and staff confirmed shortages of key menu items and improper meal preparation.
Surveyors identified that several residents consistently received food that was cold, tough, and did not match the posted menu or their dietary orders. Staff interviews revealed a lack of adherence to recipes and menu planning, and test trays showed food items not prepared as required, with some served below safe temperatures. Residents also reported not receiving alternate menu options and insufficient portions.
A resident with orders for both breakfast and lunch to be sent on dialysis days did not consistently receive both meals, with staff confirming only one meal was typically provided. Additionally, meal service times were inconsistent, and some meal components were missing or delayed, failing to meet residents' needs and preferences.
Surveyors found that staff failed to properly store and label multiple opened food items, including thickened liquids, bread, ice cream, and condiments, in both the kitchen and nourishment pantries. Several items were not sealed, not dated, or lacked use-by dates, contrary to facility policy and professional standards. These practices were confirmed by dietary management and LPNs during the investigation.
Staff failed to follow infection control protocols, including proper hand hygiene and use of PPE, for two residents on transmission-based precautions. An LPN did not perform hand hygiene between glove changes during dressing changes and incontinence care for a resident with ESBL, and a nursing assistant was unaware of updated isolation status. For another resident with C. diff, a nursing assistant entered the room without PPE and used hand sanitizer instead of soap and water after contact, contrary to facility policy.
The facility did not retain required documentation showing that residents or their representatives were educated about and either accepted or refused influenza and pneumococcal vaccines. Immunization reports indicated that some residents received or refused vaccines, but consent or declination forms were missing from their records, as confirmed by the DON.
The facility did not ensure that food service areas and resident rooms were free from flies, as evidenced by flies observed in the kitchen and dishwasher areas and reports from two residents who experienced ongoing fly issues in their rooms. Staff confirmed the presence of flies, and the administrator stated there was no specific pest control policy in place.
Soiled Air Conditioner Vents in Dining Room: A surveyor observed three large portable AC units in the main dining room, with two of the three flexible hoses/vents showing a dark, dusty, blackish substance while air was blowing into the room. The Administrator confirmed the condition of the vents.
Pharmacist drug regimen review recommendations were not consistently reviewed and addressed by the physician for three residents. One resident had overlapping NSAID orders with no documented provider review, another had a pharmacist concern about anticholinergic burden with a blank provider response, and a third had a signed recommendation for a BMP after metformin was started, but no follow-up lab result was found in the record.
Inaccurate and incomplete resident record documentation affected multiple residents. Records showed mismatched capacity findings, missing physician follow-up documentation for a psych recommendation, inconsistent FRI dates, a missing diagnosis entry, an undated POST signature, and medication orders that did not match the documented indication. The chart also contained a wound care order for the wrong foot and incomplete meal intake documentation, which the DON confirmed.
Insufficient Nurse Aide Continuing Education: Record review showed the facility did not ensure nurse aides completed at least 12 hours of annual continuing education. Three of five nurse aide records reviewed were out of compliance, including one aide with no education hours documented and two aides with fewer than 12 hours completed; each record also showed limited dementia-related training.
A deficiency was cited when a resident's care plan did not include all required elements, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
A resident on a Dysphagia Mechanical Soft diet was served regular-texture foods, including uncut spaghetti and improperly prepared zucchini, which did not meet dietary requirements. Staff failed to follow prescribed recipes and diet guidelines, resulting in the resident being unable to eat the meal provided.
Three residents did not receive meals in accordance with their documented allergies, intolerances, or preferences. One did not receive a prescribed nutritional supplement, another with a fish allergy was denied alternate menu options due to unavailable lunch meat, and a third who disliked pork was served a ham-based meal after menu substitutions. Staff confirmed food shortages and substitutions due to missed orders and staffing issues.
A resident lacked capacity to consent, and the representative had signed informed consent for several psychotropic meds, but no consent was found for Zyprexa despite an active order for olanzapine 15 mg at bedtime for schizoaffective disorder. During survey review, the DON confirmed the Zyprexa consent form could not be located.
Failure to honor a resident's end-of-life directives occurred when a resident with capacity completed a new POST form requesting CPR and full life-sustaining treatment, but the chart still contained a DNR order from a prior directive. The DON acknowledged the code status order was not updated to match the resident's changed wishes, despite the facility policy requiring advance directive decisions to be documented and communicated to the care team.
A facility failed to thoroughly investigate an allegation of resident-to-resident abuse after a resident who was NPO, tube-fed, and had profound swallowing impairment choked on food bolus and died. The investigation relied on staff and resident statements saying no one was seen feeding the resident, but it did not include evidence that another resident’s meal ticket showed meatloaf was served that evening, and the DON/Administrator later stated they could not solidly conclude the alleged perpetrator was responsible.
A resident’s PASARR was not updated after a new major mental disorder diagnosis was added. The resident’s record showed Bipolar Disorder, GAD, Major Depressive Disorder, Recurrent, Moderate, and Schizoaffective Disorder, Bipolar Type, while the MDS listed multiple psychiatric diagnoses. Surveyors found the PASARR should have been revised when the new depressive disorder diagnosis was entered, but it remained unchanged.
A resident with capacity changed his POST from DNR to full CPR and full life-sustaining treatment, but the comprehensive care plan was not revised and still listed him as DNR. The DON acknowledged the care plan was not updated after the new POST form was completed.
A resident with PTSD, delusional disorders, anxiety, anger, irritability, dementia, and paranoid personality disorder had a disposable razor left beside the sink in his private bathroom. The resident did not have capacity to make his own medical decisions, and his room and bathroom were left open while other residents were observed in the hallway. When asked about razor policy, the NHA said she would need to review the care plan to determine whether the resident was independent with razor use.
Failure to provide ordered colostomy care: A resident with a colostomy was observed with stool falling from the ostomy bag onto the floor, and record review showed the surgeon follow-up after hospital discharge was delayed and no colostomy care orders were in place for months. When an order was later entered, it was only an PRN order, and the TAR showed the care was never initialed as completed. The DON could not explain the missed follow-up or why a standing order was not entered.
A facility failed to store medications according to professional standards when an LPN found a multi-use vial of Tresiba insulin for a resident in the medication cart that had been opened but not dated when first accessed. The facility policy required opened vials to be dated, and the insulin package insert stated an opened multi-use vial could be used for 56 days.
A resident receiving divalproex sodium for dementia with mood disturbance had an order for valproic acid level monitoring every 6 months, but the record showed the last level was within normal limits and no follow-up lab had been completed as ordered. The DON confirmed the lab had not been performed on the required schedule.
Incorrect Honey-Thick Liquid Preparation
Penalty
Summary
The facility failed to ensure that a resident with a physician order for honey-thickened liquids received beverages mixed to the correct consistency. Resident #98 had orders for a regular diet, dysphagia mechanical texture, and honey-thickened liquids. During observation, the resident’s bedside cup of water labeled as thickened did not appear to meet honey-like, moderately thick consistency. Record review also showed the facility’s Diet and Nutrition Care Manual instructed staff to use two pumps of thickener per 4 oz of liquid and to stir briskly for 30 seconds, with the same directions printed on the SimplyThick bottle. Additional observations showed no honey-like pre-thickened liquids were available in the nourishment pantry refrigerator, and an LPN confirmed this. During interview, one LPN stated it takes three pumps and asked about measuring cups, then three pumps were added to 8 oz of water, resulting in a consistency that was inconsistent with honey-thick. The Unit Manager stated the resident was on the thickest green directions and incorrectly referred to spoon-thick liquid directions, and also stated aides or kitchen staff typically thicken beverages while nurses thicken only for medication administration. The resident had recently been hospitalized for septic shock, acute chronic hypoxic respiratory failure, and aspiration pneumonia, and was again provided liquids not mixed to the correct honey-thick consistency after returning to the facility.
Failure to Provide Necessary Care, Medication Administration, and Dietary Safety
Penalty
Summary
The facility failed to provide necessary care and services by not recognizing and treating changes in condition, not following physician orders for medication parameters, failing to document medication administration, and not ensuring food was provided in the correct form. Multiple residents experienced harm as a result, including one resident who was hospitalized with respiratory failure, urinary tract infection, and aspiration pneumonia after staff failed to assess and notify a physician about abnormal urinary output and repeated episodes of distress. Another resident died after being given food despite an order for nothing by mouth (NPO), with the facility failing to protect the resident from others providing food. Medication administration errors were identified for several residents. Orders for side effect monitoring of psychotropic medications were not completed on multiple occasions, and insulin was held without a physician order. Residents received medications such as Midodrine and gabapentin outside of prescribed parameters, including administration when blood pressure was above the hold threshold and dispensing more doses than ordered. Documentation was lacking for medication and treatment administration, and in some cases, there was no evidence that required monitoring or physician notification occurred after abnormal findings. The facility also failed to ensure that residents' dietary needs were met according to orders. One resident did not receive prescribed hemorrhoid cream, with no documentation to support administration. Another resident with a profound swallowing disorder and NPO order died after choking on food, with the investigation failing to determine how the food was provided and no follow-up education for staff or residents with modified diets. These deficiencies were confirmed through record review, interviews, and observations, and were acknowledged by the Director of Nursing.
Failure to Assess, Monitor, and Treat Pain According to Standards
Penalty
Summary
The facility failed to assess, monitor, and treat pain in accordance with professional standards for three residents, resulting in actual harm. For one resident, nursing staff documented multiple instances of moderate to severe pain over several months but did not provide either non-pharmacological or pharmacological interventions as ordered by the physician. The nurse also failed to assess the pain for location or duration and did not notify the physician of the resident's increased pain, despite clear orders to do so when pain was not controlled or was new in onset. Another resident experienced an increase in pain upon movement and transfers. Although pain medication was administered and later increased, staff did not assess the underlying cause of the pain, which was subsequently found to be due to two fractures. In a separate case, a resident reported numbness and tingling at an amputation site, which was communicated to the physician. The physician indicated the issue would be addressed the following day, but there was no documentation that the resident was evaluated or that treatment was prescribed, and the resident continued to experience symptoms. Additionally, for a resident who was prescribed a new pain medication, staff failed to notify the physician when the ordered medication was unavailable and did not obtain an alternative order, despite the availability of a substitute medication. This resulted in the resident not receiving pain relief in the hours prior to death. These failures were confirmed through record review, staff interviews, and resident interviews, and affected three of eight sampled residents reviewed for pain management.
Failure to Ensure Resident Dignity During Meals and Room Entry
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by providing plastic silverware during meals. On two separate occasions, the majority of residents in the main dining room and residents on the last halls were served meals with plastic utensils due to a shortage of clean regular silverware. Staff interviews confirmed that the kitchen had run out of clean silverware, and the issue persisted until it was brought to the attention of staff by the state surveyor. The use of plastic silverware was observed and acknowledged by multiple staff members, indicating a lapse in maintaining resident dignity during meal service. Additionally, the facility did not follow its own policy regarding resident privacy and dignity when a nurse aide entered a resident's room without knocking or announcing themselves. The incident was observed by a state surveyor and confirmed by the unit manager, who acknowledged that the staff member should have knocked before entering. The facility's written policy requires staff to knock and wait for an answer before entering a resident's room, but this procedure was not followed, resulting in a failure to ensure resident privacy and dignity.
Failure to Follow Menus and Provide Ordered Foods
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received the foods they wanted or ordered, as required. On multiple occasions, the kitchen ran out of key menu items, such as lunch meats and chicken tenders, resulting in substitutions that were not consistent with the posted menus. Staff confirmed that certain items listed as 'Always Available' were not in stock for several days, and that menu substitutions were made without following proper recipes or procedures. For example, zucchini was served boiled and without the required ingredients, rather than being prepared according to the facility's recipe, which called for baking with olive oil, pepper, parmesan cheese, and garlic. Staff also indicated a lack of awareness regarding the existence of recipes for menu items. A resident reported dissatisfaction with the food and was observed receiving a meal that did not match the tray ticket instructions. The resident, who was supposed to receive double fruit portions and vanilla ice cream, instead received only one fruit cup and no ice cream. The resident expressed a preference for fruit and ice cream and stated he would have eaten them if provided. The administrator confirmed that the resident had not received the correct portions as indicated on the tray ticket. These failures demonstrate that the facility did not consistently provide meals as planned or as ordered by residents, affecting the nutritional adequacy and resident choice in meal service.
Failure to Provide Palatable, Properly Prepared, and Appropriately Tempered Food
Penalty
Summary
Surveyors found that the facility failed to ensure food was prepared and served in a manner that conserved nutritive value, flavor, and appearance, and did not consistently provide food that was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, tough, and did not match the menu or their dietary tickets. One resident stated that the food was always ice cold and not as described on the menu, while another reported not receiving the ordered food due to issues in the kitchen. Residents also indicated that food was left in the hallway before delivery, contributing to it being served cold. During a test tray observation, surveyors noted that the zucchini was not prepared according to the provided recipe, as it was boiled instead of baked, lacked parmesan, and was described as bitter, tough, and rubbery. Staff interviews revealed that recipes and menus were not consistently followed, and some staff were unaware of the existence of recipes. Temperature checks of trays showed food items being served below recommended temperatures. Additionally, residents reported not receiving alternate menu options and insufficient portions, with one resident specifically noting that their breakfast order was not consistently fulfilled.
Failure to Provide Timely and Appropriate Meals for Dialysis Resident
Penalty
Summary
The facility failed to ensure that meals were provided at regular times and did not consistently provide required meals to a resident on dialysis. Specifically, a resident with a physician's order for bagged breakfast and lunch to be sent with him on dialysis days reported that the facility did not consistently send lunch, and sometimes an aide would make one, but this was infrequent. Staff interviews confirmed that only one meal, lunch, was typically sent, and not both breakfast and lunch as ordered. The Treatment Administration Record was initialed to indicate a lunch was sent, but there was no confirmation that both meals were provided as required. Additionally, observations and staff interviews revealed inconsistencies in meal service times, with lunch trays being delivered and served outside of the scheduled meal times. There were also issues with meal components, such as not having enough pears for trays, which were to be sent out later. These practices failed to ensure that meals and snacks were served in accordance with residents' needs, preferences, and requests, and did not meet the requirements for providing suitable and nourishing alternatives for residents who needed to eat at non-traditional times.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple instances of improper food storage and labeling. During a review of facility policies, it was noted that opened food items are required to be dated and stored properly, with specific instructions for dry, refrigerated, and frozen foods. However, observations in the kitchen and nourishment pantries revealed several opened food items, such as thickened liquids, spaghetti, pancake syrup, frozen green beans, chicken pot pie mix, bread, coffee, ice cream, relish, ranch dressing, and nutritional supplements, that were either not sealed, not labeled, or lacked use-by dates. Staff interviews confirmed that these items were not managed according to the facility's own policies, with some items being immediately discarded upon discovery. The deficiency was identified through record review, staff interviews, and direct observation, and it was confirmed by both the Regional Dietary Manager and LPNs responsible for monitoring food storage. The facility census at the time was 102, and the improper storage practices had the potential to affect more than a limited number of residents. No specific residents were identified as being directly affected at the time of the survey, and there were no details provided regarding the medical history or condition of any residents in relation to the deficiency.
Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in following transmission-based precautions and proper hand hygiene protocols. For one resident with pressure ulcers and an ESBL urinary tract infection, an LPN performed dressing changes and incontinence care without performing hand hygiene between glove changes, despite facility policy requiring hand hygiene when moving between contaminated and clean body sites. The LPN acknowledged not performing hand hygiene during these procedures. Additionally, a nursing assistant was observed feeding the same resident in their room without wearing required personal protective equipment (PPE), such as a gown and gloves, and was unaware of the resident's updated contact isolation status. Another resident, under contact isolation and enteric precautions for C. difficile, was also not provided appropriate infection control measures. A nursing assistant entered the resident's room to deliver and set up a meal tray without donning a gown or gloves, touched the resident and their environment, and upon leaving, used hand sanitizer instead of washing hands with soap and water as required for C. difficile precautions. The nursing assistant believed the precautions only applied to direct care, not tray delivery. The Director of Nursing confirmed that contact enteric precautions applied to all staff entering the room.
Lack of Documentation for Flu and Pneumonia Vaccine Consents
Penalty
Summary
The facility failed to provide and document influenza and pneumococcal vaccinations according to accepted standards of practice. Specifically, the facility did not retain documentation that residents or their representatives received education regarding the vaccines, nor did it retain records indicating whether the vaccines were accepted or refused. This deficiency was identified through record review and staff interview, affecting three out of five residents reviewed for immunizations. The facility's policy required that residents or their representatives complete consent or declination forms for these vaccines, but these forms were missing from the medical records. For the residents involved, immunization reports indicated that some received the influenza vaccine while others refused the pneumococcal vaccine. However, there was no supporting documentation in their records to confirm that informed consent or refusal was obtained, or that education about the benefits and potential side effects was provided. The DON confirmed that the required immunization consents and refusals could not be located, attributing the issue to missing documentation from the prior Infection Preventionist.
Failure to Maintain Pest-Free Food Service and Resident Areas
Penalty
Summary
The facility failed to ensure that food preparation and service areas, as well as resident rooms, were free from visible signs of insects, specifically flies. Observations included flies present in the dishwasher and kitchen areas, including near plates, food, and the tray line. Staff confirmed the presence of flies in these areas. Additionally, two residents reported ongoing issues with flies in their rooms, with one resident keeping a flyswatter on hand and another noting that a nurse had killed multiple flies in the room. The administrator acknowledged that while there was a QAPI initiative for flies and increased pest control services during certain months, there was no specific policy or procedure for pest control in place at the facility.
Soiled Air Conditioner Vents in Dining Room
Penalty
Summary
The facility failed to provide a homelike dining environment by allowing soiled air conditioning vents to remain in the main dining room area. During observation, three large portable air conditioners were present in the dining room, and two of the three large flexible hoses/vents were observed to have a dark, dusty, blackish substance on them while air was blowing out into the dining room. The Administrator later confirmed the soiled vents and stated, "I will remedy that immediately." The facility census was 102, and the deficiency was identified as affecting more than a limited number of residents.
Pharmacist Drug Review Recommendations Were Not Consistently Reviewed
Penalty
Summary
The facility failed to ensure that reported irregularities from the pharmacist’s monthly drug regimen reviews were reviewed and addressed by the resident’s physician for three residents. For one resident, the pharmacist noted concurrent orders for meloxicam tablets and Voltaren gel, both NSAIDs, and recommended discontinuing one order because taking them together increased the risk of side effects; there was no evidence the recommendation was reviewed by the medical provider or that any action was taken. For another resident, the pharmacist identified a new order for Unisom for insomnia and documented concern that the resident was taking multiple medications with anticholinergic effects, including Unisom, olanzapine, bupropion, and Zyrtec, with added concern due to dementia and Flomax use for urinary retention; the physician response section on the recommendation form was blank and the DON stated there was no documentation of physician review or response. For a third resident, the pharmacist recommended obtaining a BMP after metformin was started and noted the last BMP found in the electronic record was from the prior year. The attending physician marked agree and signed the recommendation indicating the BMP should be done, but the medical record contained no BMP results after the prior year’s lab. The DON confirmed the BMP was not completed.
Inaccurate and incomplete resident record documentation
Penalty
Summary
The facility failed to maintain resident medical records accurately and in accordance with accepted professional standards for multiple residents. For Resident #35, the Physician's Determination of Capacity was marked both as demonstrating capacity to make decisions and as demonstrating incapacity with a long-term duration; the Administrator and DON confirmed the resident was capacitated and said the inconsistency was a clerical error. For Resident #38, cimetidine (Tagamet) was ordered with a diagnosis of GERD without esophagitis, but the DON confirmed the medication was actually started for sexual behaviors. The same resident also had a Behavioral Health and Psychology note recommending consideration of decreasing trazodone from 100 mg to 75 mg at bedtime, but no documentation was found to support physician follow-up or the reported instruction to keep trazodone and start Tagamet. Resident #38 also had an initial FRI with inconsistent dates in the documentation: the report was faxed on 05/01/25, the incident date was listed as 05/02/25 at 11:AM, witness statements were dated 05/01/25, and abuse interviews were documented on 05/02/25. The DON confirmed the inaccurate incident dates. In addition, the DON confirmed there was no diagnosis of dementia on the resident's diagnosis list, even though dementia appeared on the PASARR and Physician's Determination of Capacity, and it was not on the medical chart or care plan when reviewed by the surveyor. For Resident #83, the POST form was signed by the HCS but was not dated, and the DON confirmed the missing date. For Resident #43, the physician order for divalproex sodium listed the medication as being for anticonvulsant use, but the DON confirmed it was being given for mood stabilization rather than seizures, and the resident's diagnosis list did not include seizures. The resident's care plan described Depakote as a mood stabilizing medication related to schizophrenia, restlessness, agitation, dementia with mood disturbance, and anxiety disorder. The resident also had a wound dressing order for the right medial foot even though the wound was documented on the left medial foot, and meal intake documentation was incomplete on 13 days over the prior 30 days, with only one or two meals recorded on those days; the DON confirmed meal intakes were not recorded at every meal.
Insufficient Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure the continuing competence of nurse aides by not providing at least 12 hours of continuing education per year. During the annual survey, record review showed this deficiency for 3 of 5 nurse aide training records reviewed: NA #5, NA #10, and NA #77. The facility census was 102. NA #5 was hired on 01/05/24 and had a Relias transcript for 08/01/24 through 07/31/25 showing 8.35 hours of education completed, including 1.5 hours related to Alzheimer's disease or dementia. NA #10, hired on 05/19/20, had a transcript for the same period showing 9.1 hours of education completed, including 2.5 hours related to Alzheimer's disease or dementia. NA #77, hired on 12/11/18, had a transcript for the same period showing no hours of education completed and 0 hours of training related to Alzheimer's disease or dementia.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the survey and was based on a review of the resident's records and care planning documentation. The deficiency was directly related to the absence of a comprehensive, individualized care plan that included all necessary components to meet the resident's needs as required by regulations.
Failure to Provide Diet-Appropriate Food Texture and Preparation
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered Dysphagia Mechanical Soft Texture diet was served a regular meal consisting of uncut spaghetti noodles, regular sliced zucchini, and a regular slice of bread. The nurse aide questioned the appropriateness of the meal, noting the resident typically received pureed food, but the Regional Dietary Manager approved the tray as served. The resident was unable to eat the meal, expressing frustration and stating he could not eat the food due to not having teeth and was supposed to receive tomato soup, which was marked out on the tray ticket. Observations confirmed the food provided did not match the resident's dietary needs or the facility's diet order. Further investigation revealed the zucchini was not prepared according to the facility's recipe or the National Dysphagia Diet (NDD) guidelines. The zucchini was boiled, not baked, and was served in large, tough pieces that were difficult to chew and not consistent with the required texture for a mechanical soft diet. Staff interviews indicated a lack of adherence to recipes and menu guidelines, with some staff unaware of the existence of recipes or proper procedures for preparing food to meet specific diet consistencies. The facility's own diet manual and addendum specified requirements for chopped vegetables and mechanical soft diets, which were not followed in this instance.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to provide food in accordance with residents' documented preferences, allergies, and intolerances for three of thirteen residents reviewed. One resident did not receive a prescribed frozen nutritional supplement as indicated on their tray card, and the supplement was only provided after intervention by a state surveyor. Another resident, who reported a fish allergy, requested an alternate sandwich but was told there was no lunchmeat available and did not receive the requested cottage cheese and fruit, instead receiving chicken strips. Staff confirmed that the kitchen had been out of lunch meat for several days. A third resident, who had a documented dislike of pork, received a meal containing ham instead of the expected beef in a macaroni casserole. The resident reported having previously informed staff of this preference and resorted to eating a peanut butter and jelly sandwich instead. The Regional Dietary Manager confirmed that due to staffing issues and a missed food order, the facility had to make emergency substitutions, resulting in the use of ham in place of beef. These incidents demonstrate that the facility did not consistently accommodate residents' dietary needs and preferences as required.
Missing Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident's representative of the benefits and risks of a psychotropic medication. Resident #6 had orders for Zyprexa (olanzapine) 15 mg by mouth at bedtime for schizoaffective disorder, and the medical record showed the resident lacked capacity to provide informed consent. The representative had signed informed consent on 12/04/24 for Lorazepam, Zoloft, and Haloperidol, but there was no informed consent in the record for Zyprexa. During the survey, this missing consent was requested, and the DON verified on 08/13/25 at 10:35 AM that she could not locate a consent form for Zyprexa.
Failure to Update Code Status After New POST Form
Penalty
Summary
The facility failed to honor a resident's right to establish directives regarding end-of-life care. Resident #23 had a physician's determination of capacity indicating the resident could make medical decisions, and the electronic health record included a Virginia Physician's Order for Scope of Treatment (POST) form showing the resident wanted CPR if pulseless and breathless and wanted full attempts to sustain life by all medically effective means. This POST form reflected a change from the resident's previous POST form, which had indicated the resident did not want to be resuscitated in the event of cardiac arrest. Despite the updated POST form, the resident's physician orders still showed a DNR order written on a prior date. The Director of Nursing acknowledged that the resident's code status order was not updated when the resident completed the new POST form indicating changed end-of-life wishes. The facility policy stated that decisions regarding the resident's medical order for life-sustaining treatment and/or advance directive would be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.
Incomplete Investigation of Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving a resident who was coded after choking on food bolus and later died. The resident had a stroke history, was ordered NPO, and received nutrition via enteral feeding. A speech therapy evaluation documented profound/absent swallowing abilities, little to no attempts to initiate or participate, and profound global aphasia with no verbalizations or voicing noted during the assessment. The death certificate listed the cause of death as choking on food bolus. The facility’s investigation concluded the allegation was not verified because staff and resident statements did not show anyone feeding the resident, and no tray was observed in the room. However, the investigation did not include information that the alleged perpetrator’s meal ticket showed meatloaf was served that evening. The alleged perpetrator stated she did not help the resident eat dinner but said the resident was hungry and had not eaten in two days, while another resident stated she was in the room talking with the alleged perpetrator when the choking occurred and did not see anyone feed the resident. During interview, the Administrator stated the resident’s oxygen saturations decreased and she was sent to the hospital, and that the investigation led to the conclusion that a meal was not served and they could not solidly conclude the alleged perpetrator did it.
Failure to Update PASARR After New Major Mental Disorder Diagnosis
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASARR) when a new diagnosis of a major mental disorder was added for one resident reviewed during the annual survey. Resident #6 had a PASARR completed by the facility on 11/07/24, which listed Bipolar Disorder, unspecified, and Generalized Anxiety Disorder, and indicated that a Level II evaluation was not required. The resident’s medical record also listed mental health diagnoses including Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Recurrent, Moderate, and Schizoaffective Disorder, Bipolar Type. The Minimum Data Set for the resident was last updated on 07/28/25 and showed active psychiatric/mood disorder diagnoses of Anxiety Disorder, Depression (other than bipolar), Bipolar Disorder, and Schizophrenia. Comparing the PASARR and the MDS, the PASARR should have been updated when Major Depressive Disorder, Recurrent, Moderate was added to the resident’s diagnoses. This finding was reviewed with the DON and the Nursing Home Administrator on 08/19/25, and neither provided additional information to clarify the finding.
Care Plan Not Updated After Change in End-of-Life Wishes
Penalty
Summary
The facility failed to revise Resident #23’s comprehensive care plan when the resident’s wishes for end-of-life treatment changed. Record review showed the resident had a physician’s determination of capacity, indicating he had the capacity to make medical decisions, and later completed a new Virginia Physician’s Order for Scope of Treatment (POST) form stating he wanted CPR in the event of pulselessness and breathlessness and full attempts to sustain life by all medically effective means. The resident’s previous POST form had indicated that he did not want to be resuscitated in the event of cardiac arrest. Despite this change in the resident’s documented end-of-life preferences, the comprehensive care plan continued to list the resident as having a DNR, with interventions stating that code status would be established at admission/re-admission and reviewed quarterly and as needed. The DON acknowledged that the care plan was not revised after the new POST form was completed.
Unsafe Razor Left Accessible in Resident Bathroom
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for one resident reviewed during the annual survey. Resident #10 had diagnoses of PTSD, delusional disorders, anxiety, anger, irritability, dementia, and paranoid personality disorder, and did not have capacity to make his own medical decisions. During a surveyor visit, a disposable razor was observed lying beside the resident’s sink in the bathroom of his private room. The resident was not in the room at the time, and his room and bathroom doors were left open while several other residents were observed wandering or sitting in wheelchairs in the hallway outside the room. When asked about the facility’s policy regarding razors, the NHA stated she would need to review the resident’s care plan to determine whether he was independent with razor use.
Failure to Provide Ordered Colostomy Care
Penalty
Summary
Resident #85 did not receive colostomy care in accordance with professional standards and the resident’s needs. During an observation on the first day of the survey, the resident was seen leaving his room when bowel movement was observed falling from the colostomy bag onto the floor, and a nurse assisted him back to his room. The resident had been admitted to the facility on [DATE], and a hospital discharge summary dated [DATE] stated he was to follow up with the surgeon regarding his colostomy in 2-4 weeks after discharge. That follow-up was not completed until 11/22/24, and the DON stated on 08/18/25 that she was unable to explain why it was missed and that there was no documentation to show why the follow-up was not completed on time. Record review also showed that from 08/02/24 through 02/18/25 there were no physician orders for colostomy care. On 02/18/25, an order was entered for cleaning the ostomy with soap and water, drying, applying skin prep and allowing it to dry, then applying colostomy adhesive powder and colostomy barrier as needed. This was the only active colostomy care order at the time of review. Review of the treatment administration record from 02/18/25 through 08/18/25 showed the care had not been initialed as completed on any occasion. The DON confirmed the care had not been initialed as given and stated she did not know why an order for the colostomy was not entered that was not an as-needed order.
Undated Multi-Use Insulin Vial
Penalty
Summary
The facility failed to store medications in accordance with professional standards of practice when a multi-use vial of Tresiba insulin for Resident #107 was found in the D hallway medication cart without a date indicating when it was first opened. The facility policy titled, Vials and Ampules of Injectable Medications, stated that when a medication vial is opened, the nurse should record the opened date on the vial. During inspection of the medication cart with an LPN, surveyors observed that the vial had been delivered to the facility by the pharmacy on 08/08/2025 and had been opened, but it was not dated when first accessed. The LPN confirmed that the vial had not been dated to show when it should be discarded. The Tresiba insulin package insert indicated that an opened multi-use vial could be used for 56 days.
Failure to Complete Ordered Valproic Acid Lab Monitoring
Penalty
Summary
The facility failed to follow a physician’s order for laboratory testing for Resident #43, who was receiving divalproex sodium 250 mg three times daily for dementia with mood disturbance. The resident had an order for valproic acid level testing every 6 months or every 182 days, but the medical record showed the last valproic acid level was performed on 02/05/25 and was within normal limits, and no valproic acid laboratory testing had been performed thus far in August. On 08/19/2025 at 5:25 PM, the DON confirmed that a valproic acid level had not been performed every 6 months or every 182 days.
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 103 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 Hinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Main Street Care | 5.7 mi | ★★★★★ | 7 | 0 |
| Lindside Healthcare Center | 13.3 mi | ★★★★★ | 24 | 0 |
| Heritage Hall-rich Creek | 17.7 mi | ★★★★★ | 0 | 0 |
| Lewisburg Healthcare Center | 18.9 mi | ★★★★★ | 11 | 1 |
| Raleigh Center | 19.2 mi | ★★★★★ | 13 | 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.