Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sundale Nursing Home during CMS and state inspections, most recent first.
A resident with a history of falls, impaired mobility, incontinence, CVA with R-sided hemiplegia, and arthritis had an order for low-profile bedside mats to be on the floor at all times while in bed. During observation, one mat was against the air unit, one was on the right side of the bed, and the left side had no mat in place; an OTA said he would report it to a nurse and replace the mat.
Expired Glucerna supplements were found in a resident nutrition room cabinet accessible to residents during a surveyor walkthrough. An SW confirmed the items were expired, showing a failure to store food in accordance with professional standards for food safety.
QAA meetings were not held at least quarterly. Record review showed the Quarter Two meeting was combined with the Quarter Three meeting, and the Administrator stated the Doctor could not attend the scheduled Quarter Two meeting, confirming no meeting occurred during the second quarter. The facility census was 91.
The facility did not document or maintain records of resident grievances as required by policy. No grievance forms or logs were filled out for the past two years. The Social Services Director stated that no grievances were received, and concerns were handled by individual departments. The Administrator noted that only explicitly stated formal grievances were documented, while other issues were treated as informal complaints.
The facility failed to accurately monitor weights for three residents, resulting in significant discrepancies. One resident lost 16.8 pounds over 37 days without documentation or intervention. Another experienced weight fluctuations while on diuretic therapy, which were not investigated. A third resident had rapid weight changes over consecutive days, with no action taken. The facility's protocol for notifying nurses of significant weight changes was not followed, and the DON confirmed that inaccurate weighing techniques were to blame.
The facility failed to notify physicians of significant weight changes in residents, leading to a lack of medical evaluation. A resident lost 16.8 pounds over 37 days without physician notification. Another resident experienced both weight loss and gain, with no investigation or physician notification, despite being on diuretic therapy. A third resident had sudden weight fluctuations, but the physician was not informed. The facility's protocol for notifying nurses of weight changes was not followed, and the DON confirmed inaccurate weighing by staff.
The facility was found to improperly store medical ice packs in the residents' pantry freezer, as confirmed by the Dietary Manager. This practice does not comply with safe and sanitary food storage standards.
The facility did not provide evidence that the LTC Ombudsman was notified of hospital transfers for two residents. One resident was transferred on two occasions, and another was transferred once, without documentation of Ombudsman notification. Staff admitted to being behind on the notification log.
A facility failed to update the PASARR for a resident diagnosed with Major Depressive Disorder (MDD). The PASARR completed earlier did not include any mental disorder diagnoses, and despite the resident being diagnosed with MDD later, the PASARR was not updated. Interviews with the DON and DSS confirmed the oversight.
A facility failed to develop and implement a comprehensive care plan for a resident diagnosed with Major Depressive Disorder (MDD). The care plan addressed the side effects of psychotropic medications but did not specifically address the needs of the resident with MDD. Both the Director of Nursing and the Director of Social Services confirmed the care plan's inadequacy, placing the resident at risk of not receiving services that meet their needs.
A facility failed to follow physician orders for a resident's pain medication, administering Hydrocodone-Acetaminophen outside the prescribed parameters for severe pain. The medication was given when the resident's pain levels were below the specified range of 7 to 10, as recorded in the Medication Administration Records. The DON acknowledged the error, noting it was made by the same nurse.
A facility failed to complete a comprehensive social services assessment for a resident, leaving several questions unanswered. These included the date of capacity determination by a physician, the resident's competency status, and current pain medications. The resident had a legal guardian and conservator since 2013 and was prescribed Tramadol for pain management. The Director of Social Services acknowledged the oversight.
Failure to Use Ordered Bedside Mats
Penalty
Summary
The facility failed to implement Resident #79’s care plan by not using both floor mats for a resident with a history of falls. On 05/27/26 at 12:31 PM, one fall mat was observed against the air unit, one fall mat was on the resident’s right side of the bed, and there was no fall mat on the left side of the bed. At 12:32 PM, Occupational Therapy Assistant #164 was asked about the mat and went to find a nurse; he returned without a nurse and observed the fall mat leaning against the heating/air unit, stating that it usually meant there was an order for it and that he would put it back down on the left side of the bed. The resident’s physician order dated 11/11/25 directed bed side mats (low profile) on the floor at all times while in bed, and the care plan identified the resident as at risk for serious injury related to a history of falls, impaired mobility, incontinence, cerebrovascular accident with right-sided hemiplegia, arthritis, and other conditions, with the approach of low profile mats on the floor beside the bed.
Expired Glucerna Found in Resident Nutrition Room
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety when surveyors found five expired Glucerna supplements in the first-floor south wing resident nutrition room during a walkthrough and inspection of the nutrition areas. The supplements were located in a cabinet accessible to residents and had expired on 01/03/26. During an interview, Social Worker #148 confirmed the supplements were expired.
QAA Committee Meetings Not Held Quarterly
Penalty
Summary
Quality Assessment and Assurance (QAA) meetings were not completed at least quarterly. Record review showed the Quarter Two QAA meeting was held on 10/29/25 along with the Quarter Three meeting, and during an interview on 06/03/26 at approximately 11:30 AM, the Administrator stated the facility normally holds meetings the month after each quarter ends to discuss items for that quarter. The Administrator also stated the Doctor was unable to attend the scheduled Quarter Two meeting, so the Quarter Two and Quarter Three meetings were combined, confirming that no meeting was held during the second quarter. The facility census was 91.
Failure to Document and Maintain Grievance Records
Penalty
Summary
The facility failed to document and maintain records of resident grievances, as required by their policy. The policy mandates that the grievance official is responsible for overseeing the grievance process, including receiving, tracking, and maintaining evidence of grievance results for at least three years. However, a record review revealed that no grievance forms or logs were filled out for the past two years. During interviews, the Social Services Director stated that the facility had not received any grievances in the last two years and did not keep a list of concerns, as each department handled complaints independently. The Administrator further explained that only concerns explicitly stated as formal grievances by residents or their representatives were documented, while other issues such as care, treatment, medication, lost items, or perceived rudeness were considered informal complaints and not logged as grievances.
Inaccurate Weight Monitoring Leads to Significant Discrepancies
Penalty
Summary
The facility failed to ensure accurate weight monitoring for three residents, leading to significant discrepancies in recorded weights. Resident #24 experienced a weight loss of 16.8 pounds over 37 days, which was not documented or addressed by the nursing staff. The resident's care plan indicated potential issues with fluid status, but there was no evidence that the weight loss was monitored or reported. Resident #53's records showed a weight loss of 5.5 pounds in 11 days, followed by a significant weight gain of 14.7 pounds over 19 days. Despite the resident being on diuretic therapy, which typically causes weight loss, the weight gain was not investigated or reported to the physician. The resident was also on hospice care, and the nutritional assessment noted significant weight changes without further action. Resident #78's records revealed a weight gain of 13.6 pounds in one day and a loss of 11.8 pounds the previous day. The dietitian's note acknowledged significant weight changes over several months, but there was no indication that these fluctuations were addressed. The facility's protocol required notifying a nurse of weight changes over five pounds, but this was not followed. The Director of Nursing confirmed that inaccurate weighing techniques contributed to these discrepancies.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician of significant changes in residents' weights and did not ensure that medical evaluations were conducted for these changes. Resident #24 experienced a weight loss of 16.8 pounds over 37 days, which was not documented or reported to the physician. The resident's care plan included monitoring for signs of dehydration and weight loss, but there was no evidence that the nurse was aware of the weight loss or that the physician had been notified. Resident #53 experienced both a weight loss of 5.5 pounds in 11 days and a significant weight gain of 14.7 pounds over 19 days. Despite a nutritional assessment noting significant weight gain and the resident's admission to hospice, there was no documentation that the weight gain was investigated or that the physician was notified. The resident was on diuretic therapy, which typically causes weight loss, not gain, further indicating the need for physician notification. Resident #78 had a weight gain of 13.6 pounds in one day and a weight loss of 11.8 pounds in another day. A dietitian's note acknowledged significant weight changes over several months, but there was no documentation that the physician was notified of these sudden changes. The facility's protocol required notifying a nurse of any weight change of five pounds or more, but this was not followed. The Director of Nursing confirmed that the weight changes were due to inaccurate weighing by staff, and the QA Trainer noted that the issue was with staff weighing techniques, not the scales.
Improper Storage of Medical Ice Packs in Resident Pantry
Penalty
Summary
The facility failed to store food in a safe and sanitary manner by placing medical ice packs in the freezer located in the residents' pantry. This was observed during a tour of the Two South Resident Pantry. The Dietary Manager confirmed that medical ice packs should not be stored with resident food, indicating a lapse in adherence to proper food storage protocols.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide evidence that the long-term care Ombudsman was notified of hospital transfers for two residents during the survey process. Resident #28 was transferred to the hospital on 09/28/24, and although the Notice of Transfer/Discharge was given to the resident, there was no evidence that a copy was sent to the Ombudsman. The Director of Social Services admitted to being behind on the notification log, which was typically updated no less than yearly. Similarly, Resident #4 was discharged to the hospital on two occasions, 09/29/24 and 11/30/24, without documentation that the Ombudsman was notified. The Social Worker confirmed the absence of evidence for these notifications, citing a backlog in the Transfer or Discharge log.
Failure to Update PASARR for Resident with Major Depressive Disorder
Penalty
Summary
The facility failed to identify and update the Preadmission Screening and Resident Review (PASARR) for a resident diagnosed with Major Depressive Disorder (MDD). During a record review, it was found that the PASARR completed in March 2024 did not include any diagnoses of Mental Disorder or Intellectual Disability for the resident. However, the resident was diagnosed with MDD in November 2024, and the PASARR was not updated to reflect this new diagnosis. Interviews with the Director of Nursing and the Director of Social Services confirmed that the PASARR and Care Plan had not been updated to include the MDD diagnosis.
Deficiency in Comprehensive Care Plan for Resident with MDD
Penalty
Summary
The facility failed to ensure that a resident had a person-centered, comprehensive care plan developed and implemented to meet their preferences and goals, specifically addressing their medical, physical, mental, and psychosocial needs. This deficiency was identified during a review of the care plan for a resident diagnosed with Major Depressive Disorder (MDD). The care plan included interventions for managing the side effects and complications of psychotropic medications prescribed for MDD but did not specifically address the needs of the resident with MDD. The resident was also a hospice patient with terminal diagnoses of hypertension and heart disease with heart failure. The Director of Nursing confirmed that the care plan addressed the side effects and complications of the psychotropic medications but did not specifically address the needs of a resident with MDD. The Director of Social Services also confirmed that the care plan had not been updated to reflect and address the diagnosis of MDD. This oversight placed the resident at risk of not receiving services that would meet their desires or needs, as the care plan did not comprehensively address the resident's highest practicable well-being.
Failure to Follow Physician Orders for Pain Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of pain medication for a resident. The resident had a physician order for Hydrocodone-Acetaminophen to be administered for severe pain levels ranging from 7 to 10. However, a review of the Medication Administration Records for December 2024 and January 2025 revealed that the medication was administered on several occasions when the resident's pain level was below the specified range, with pain levels recorded as 6, 3, and 3 on different dates. This discrepancy was acknowledged by the Director of Nursing during an interview, who noted that the same nurse was responsible for the errors.
Incomplete Social Services Assessment for a Resident
Penalty
Summary
The facility failed to complete a comprehensive social services assessment for a resident, identified as Resident #35. During a record review, it was discovered that several questions on the assessment, dated June 25, 2024, were left unanswered. These questions pertained to the date capacity was determined by a medical doctor, the resident's competency status regarding guardianship or conservatorship, and current pain medications. Further review of the records showed that the most recent physician determination of capacity was on May 22, 2024, and the resident had both a court-appointed legal guardian and conservator since January 28, 2013. Additionally, the resident was prescribed Tramadol for pain management starting July 20, 2023. The Director of Social Services acknowledged during an interview that these questions were indeed left blank and unanswered.
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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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Nursing homes near Morgantown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morgantown Healthcare Center | 0.1 mi | ★★★★★ | 10 | 0 |
| Morgantown Heights Of Journey | 0.8 mi | ★★★★★ | 8 | 0 |
| Madison, The | 1.6 mi | ★★★★★ | 7 | 1 |
| Majestic Care Of Manchin | 16 mi | ★★★★★ | 0 | 0 |
| Fairmont Medical Center | 16.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.