Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Teays Valley Center during CMS and state inspections, most recent first.
RN Staffing Requirement Not Met: Surveyors found that the facility did not have an RN on duty for 8 hours a day, 7 days a week, full time. The Daily Nurse Staffing Form showed only one RN working 4 hours, and the NHA confirmed the RN was on call and came in for 4 hours. The finding was verified by the facility timekeeping report.
Surveyors found that staff failed to provide and accurately document ADL assistance for multiple residents, including oral hygiene and scheduled showers. One resident’s oral care was marked as “not applicable” without any indication of refusal, and another resident had severe dental plaque despite a care plan requiring twice-daily teeth brushing. The DON acknowledged that staff were using “not applicable” instead of documenting refusals. A resident with Dementia and Parkinson’s Disease, who depended on staff for ADLs and preferred showers, was scheduled for twice-weekly showers but received only a few showers and bed baths over a month, with several missed showers recorded as “not applicable.”
The facility failed to maintain an effective pest control program and adequate environmental cleanliness, as evidenced by mouse droppings observed in the dining area and in multiple resident rooms and bathrooms, along with resident reports of seeing mice. Surveyors found large amounts of dark, cylindrical pellets on dining room countertops, in utensil drawers, and in cabinets, while several residents reported mice in their rooms and noted poor cleaning. Observations included food debris on floors and linens, holes in walls behind commodes, loose baseboards with openings, damaged drywall, and debris on and around resident furniture, with staff acknowledging ongoing mouse issues and the need for cleaning and repairs.
A facility failed to verify that a bed hold notice was given to a resident or the resident’s legal representative when the resident was transferred to an acute care facility for SOB with hypoxemia. The resident had decision-making capacity, but the medical record contained no bed hold notice, and the notice later provided by the NHA was not signed by the resident. The NHA acknowledged that a signature should have been obtained or verbal consent documented.
Care plans were not fully developed or carried out for three residents. One resident with Bipolar disorder did not have that diagnosis included in the care plan, another resident was supposed to receive showers but was often given bed baths instead, and a third resident had a care plan intervention for a Defined Perimeter Mattress that was not being implemented as documented.
Unsanitary food storage and kitchen conditions: Surveyors observed widespread food debris, sticky residue, black flaky buildup, and possible pest droppings on kitchen equipment, refrigerators, prep tables, ovens, carts, floors, walls, cabinets, and in the dish room. Items were also stored improperly, including food cases on the floor or touching the ceiling, an open undated thickened tea container, and missing food temp logs across multiple meals.
COVID-19 Vaccination Documentation and Administration Deficiencies: The facility failed to educate, offer, and document COVID-19 vaccination status for several residents. Record review showed multiple residents lacked evidence of receiving the current COVID-19 boosters, and in some cases there was no consent or declination on file. In other cases, a resident or representative had consented, but the vaccine was not administered, and the DON confirmed the omissions.
A resident reported that the facility served oatmeal and eggs every day, despite her not wanting those foods and being lactose intolerant. She stated staff had not asked about her food preferences. The Dietary Manager later confirmed no dietary preferences were on file, even though the care plan directed staff to honor the resident's food preferences within the meal plan.
A facility failed to maintain a safe, clean, comfortable, homelike environment when privacy curtains were found with missing brackets and visible dirt/stains, and resident room walls and trim showed torn, peeling, missing, and scratched surfaces. The NHA reviewed the observations with the surveyor and acknowledged prior maintenance auditing, but the noted hallway work had not yet begun.
The facility failed to administer RSV vaccines to two residents even though consent had already been obtained from their health care decision makers and the vaccines were addressed under facility policy and CDC/ACIP guidance. During record review, the DON confirmed both residents should have received the RSV immunization by the time of survey review but did not know why it had not been given.
A resident with a contracture and limited ROM was supposed to receive a left resting hand splint daily as tolerated, with staff to attempt fitting 2 fingers under the straps. The care plan did not address the hand splint, task records showed no documented attempts to apply heel protectors, and survey observations found no orthotics in place. PT/OT notes did not reference the hand splint and instead suggested heel protectors, while 2 months of task records showed no care for either splinting.
A resident with a physician order for a defined perimeter mattress as a fall intervention was found with a standard mattress on the bed instead. An RN confirmed the mattress in place was standard and acknowledged it did not match the ordered defined perimeter mattress, which is built up on the edges to help prevent the resident from falling out of bed.
Personal refrigerators in several resident rooms were not being monitored or maintained per policy. Surveyors found missed temp checks, dirty refrigerators, and unlabeled or expired food items in multiple rooms, including one refrigerator with a leaked drink and another with expired dip. The Administrator was shown the findings and confirmed they had not been addressed as they should.
A resident with capacity to make own decisions had diagnoses of anxiety, depression, and insomnia and was prescribed Sertraline and Trazodone. The medical record did not contain documentation that the resident was informed of the risks and benefits of these medications, and although the DON said the resident gave verbal consent and refused to sign the consent forms, the verbal consent was only signed by one staff witness and was not co-signed by a second party.
A resident did not receive the influenza vaccine in a timely manner even though the resident’s representative had already consented to it. During record review, the DON confirmed the vaccine should have been administered and did not know why it had not been given, despite the facility policy calling for timely immunization to support peak flu-season immunity.
A resident with a recent history of falls, persistent disorientation, chairbound status, predisposing diseases, and medications increasing fall risk was admitted and assessed as high fall risk. Despite these factors and a subsequent fall, the care plan did not include fall risk interventions until after the incident. The DON confirmed the omission of fall risk in the care plan prior to the fall.
The facility failed to provide liquids in the correct consistency for residents requiring nectar thickened liquids, creating an immediate jeopardy situation. Observations revealed that residents had liquids that were not of the required consistency, and staff interviews indicated improper preparation of thickened liquids. Staff were not following the manufacturer's guidelines for thickening, leading to potential risks for residents.
The facility failed to ensure a clean and well-maintained environment in three resident rooms. Issues included stained blinds, a pink substance on the floor, improperly fitted toilet tank lids, dislodged and dusty light fixtures, and unaddressed resident requests for wall and ceiling maintenance. These deficiencies were confirmed by a Corporate RN.
The facility failed to provide accurate MDS assessments for five residents, leading to discrepancies in their medical records. A resident was noted as having adequate hearing despite being hard of hearing, another had an undocumented IV port, and a third had a cancer diagnosis omitted. Additionally, a resident was incorrectly documented as receiving insulin, and another was inaccurately noted as edentulous. These errors were confirmed by staff and could impact care planning.
The facility failed to implement comprehensive care plans for several residents, leading to improper documentation and execution. A resident's care plan was not followed regarding blood pressure monitoring, while others lacked documentation of religious preferences and food allergies. Additionally, there were significant gaps in monitoring nutritional intake for residents with weight loss, and some care plans did not address medical diagnoses like epilepsy and cirrhosis.
The facility failed to update care plans for several residents, including one who experienced an actual fall, another with a nutritional supplement order, a resident with an incorrect diabetes diagnosis, and a resident with unaddressed psychiatric diagnoses. These deficiencies were confirmed by facility staff.
A resident dependent on staff for showering did not receive the scheduled showers and bed baths. From September to December, the resident received only 10 out of 29 scheduled showers and 19 out of 72 bed baths, with one documented refusal. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to adhere to care plans and physician orders for four residents, resulting in inadequate care. A resident with constipation did not receive prescribed treatments, another with a Foley catheter had no urinary output documentation, a third wore a splint without a physician's order, and a fourth had blood pressure taken from a restricted extremity. These deficiencies were confirmed by facility staff.
The facility failed to maintain proper nutritional care for several residents, resulting in significant weight loss and incomplete meal documentation. A resident did not receive prescribed supplements, while another had incomplete meal intake records. A third resident experienced severe weight loss with missing meal documentation, and another had a downward weight trend with incomplete records. The DON and Corporate RN confirmed the documentation issues.
The facility failed to manage food allergies for three residents, leading to a severe allergic reaction for one resident who was served shrimp despite a shellfish allergy. Other residents had inaccuracies in their allergy documentation, and none had allergies documented in their care plans. Interviews revealed inadequate procedures for communicating and verifying food allergies.
The facility failed to store and label food items according to professional standards, as observed during a kitchen investigation. Unlabeled and undated food items, such as a Ziploc bag of soup, an opened pie crust, and a trash bag of French bread loaves, were found. Additionally, serving utensils were improperly stored with handles turned in different directions. These issues were confirmed by the Certified Dietary Manager (CDM), who acknowledged the deficiencies.
The facility failed to properly dispose of garbage, with trash overflowing from a can under the kitchen handwashing sink and onto clean pots and baking sheets. Garbage was also found on a storage rack with clean items. In the dining room, food, dirty napkins, and straws were observed on tables and the floor, with dirty silverware left on tables. The Certified Dietary Manager confirmed these findings during an investigation.
The facility failed to maintain accurate and complete medical records for several residents. Observations revealed discrepancies in dental assessments, meal documentation for a resident on NPO status, and missing diagnoses in PASRR. Additionally, vaccination records were incomplete, and attempts to contact the MPOA were not documented.
A facility failed to provide accurate and timely discharge notices for a resident during transfers to an acute care facility. Documentation was incomplete or incorrect for two of the three transfers, with one form listing an incorrect date and another transfer lacking a form entirely. This was confirmed by the DON.
The facility failed to identify and document mental health diagnoses for two residents in their PASARR process. A resident's diagnoses of Bipolar Disorder and PTSD were not identified, and another resident's Bipolar Disorder was omitted from the PASARR, despite being present in medical records. These discrepancies were confirmed by a State Surveyor and a Corporate RN.
A facility failed to document a resident's religious preferences and history as a minister in their care plan, leading to a lack of appropriate activity invitations. The resident, who identified with the Baptist faith, expressed that they were not invited to activities that aligned with their beliefs, such as church services, and did not participate in bingo due to personal beliefs against gambling. This deficiency was confirmed by the Administrator.
A facility failed to evaluate a resident's hearing impairment, despite the care plan recognizing impaired communication due to hearing issues. The medical record lacked documentation of a hearing test or assessment for hearing aids. The DON confirmed that no hearing assessment had been conducted since the resident's admission.
A resident was found to have long, curled toenails due to the facility's failure to provide proper foot care. The resident's medical record showed no diagnosis preventing nail care, and there was no record of a podiatrist visit. The DON confirmed the need for nail trimming and acknowledged the oversight.
A facility failed to use proper PPE for a resident in Enhanced-Barrier Precautions (EBP) due to wounds, a suprapubic catheter, and a feeding tube. A nurse aide provided ADL care without wearing a gown and gloves, and both an RN and an LPN did not don PPE before wound care. The EBP signage was turned backward, contributing to the oversight, as acknowledged by the DON.
A resident's healthcare decision maker was not given complete or accurate information regarding available Medicaid bed-hold days or the cost per day when the resident was transferred to a hospital on multiple occasions. Bed-hold notices were incomplete and lacked documentation that the responsible party was informed or made decisions about paying for the bed-hold.
RN Staffing Requirement Not Met
Penalty
Summary
The facility failed to have a Registered Nurse on duty for eight hours a day, seven days a week, full time. During record review and staff interview, surveyors found that on 04/21/25 the facility Daily Nurse Staffing Form showed only one RN working 4.0 hours. On 02/18/26 at 12:15 PM, the surveyor asked the Nursing Home Administrator whether the posted staffing form was correct, and the NHA stated the RN was on call but came in to work four hours that day. This was also verified by the facility's Time Detail Report from the time keeping system. The deficiency was identified for one of 19 days reviewed during the survey process, with a facility census of 120.
Failure to Provide and Accurately Document ADL Hygiene and Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and accurately document assistance with activities of daily living (ADLs), specifically hygiene and bathing, for multiple residents. For one resident, review of hygiene task documentation on a specific date showed oral care marked as “not applicable” without any indication that care was refused, making it appear that no attempt was made to provide oral care. Another resident was observed to have severe plaque buildup on their teeth despite a care plan that required teeth brushing twice daily. During an interview, the DON confirmed that staff were incorrectly selecting “not applicable” instead of documenting when a resident refused care, which made it appear that required care was not provided rather than refused. A third resident’s MPOA reported that the resident often appeared unkempt and that she frequently had to remind staff of the resident’s scheduled shower days; she stated that both she and the resident preferred showers and that staff were aware. Record review showed this resident required assistance or was dependent for multiple ADLs, including bathing, grooming, and personal hygiene, and that it was important to the resident to have a shower. The resident had diagnoses of Dementia and Parkinson’s Disease and was scheduled for showers twice weekly on day shift. Over a 30‑day period, the resident was eligible for eight showers but received three showers and two bed baths, with several scheduled shower days documented as “not applicable.” The DON confirmed that the resident did not receive showers as scheduled.
Failure to Maintain Effective Pest Control and Environmental Cleanliness
Penalty
Summary
The facility failed to ensure an effective pest control program was in place, as evidenced by repeated observations of mouse droppings and resident reports of mice in multiple areas. The written pest control policy, shared between Dining Services and the facility, focused on food preparation, service, and storage areas and referenced coordination between the Dining Service Director and Director of Maintenance for pest control services. During an initial tour of the dining room, surveyors observed a large amount of small, dark brown-to-black, cylindrical pellets resembling grains of rice on the countertop along the wall/backsplash, in utensil drawers, in a cabinet labeled for a suction machine, and in a drawer labeled for clothing protectors. Staff present during these observations acknowledged prior issues with mice and stated the area needed to be cleaned, but the pellets remained present when rechecked later the same day. Multiple residents reported seeing mice in their rooms within the prior week, and surveyors observed environmental conditions consistent with pest activity and inadequate cleaning. One resident stated that rooms did not get cleaned properly and had food debris on the floor under the bed, on bed linens, and around the bathroom sink. Another resident reported seeing a mouse under a roommate’s cabinet, where surveyors then observed several small, dark brown-to-black, cylindrical pellets along the floor near the wall and a large amount of debris on top of the cabinet. Additional residents reported mice coming from bathrooms and under closets; in these rooms, surveyors observed holes in walls behind commodes, loose baseboards with holes, damaged drywall, and mouse-like pellets on the floor behind commodes and in corners. Staff, including a CNA and the Administrator, confirmed the presence of debris, wall holes, and the need for cleaning and repairs in these resident rooms and bathrooms.
Missing Bed Hold Notice Verification
Penalty
Summary
The facility failed to ensure there was verification that a bed hold policy or notice had been given to Resident #50 or the resident’s legal representative when the resident was transferred from the facility. Resident #50 had capacity to make his or her own medical decisions and was on hospital leave from 08/22/25 until 08/27/25. On 08/22/25, the resident was transferred to an acute care facility for shortness of breath with hypoxemia. A review of the medical record found no bed hold notice, and when the notice was later requested from the facility on 02/17/26, the bed hold notice provided by the NHA was not signed by the resident. The NHA acknowledged that signatures should have been obtained or verbal consent documented.
Care Plans Not Developed or Implemented as Documented
Penalty
Summary
Failure to develop and implement complete care plans was identified for three residents. Resident #3 had a diagnosis of Bipolar disorder, but the care plan did not include Bipolar under the focus of impaired/decline in cognitive function or impaired thought processes, and it was confirmed with the Administrator that the diagnosis was not developed on the care plan. Resident #9’s care plan identified a preference for showers, and the resident’s Medical Power of Attorney confirmed this preference during a telephone interview, but the GG-bathing task record showed the resident was not receiving showers as outlined and was instead often receiving bed baths. Resident #63 had a physician’s order for a Defined Perimeter Mattress for safety, and the care plan listed this intervention under the fall-risk focus, but the Administrator confirmed the care plan was not being implemented to ensure the resident was provided the Defined Perimeter Mattress as outlined.
Unsanitary food storage and kitchen conditions
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner, and failed to keep the kitchen cleaned in accordance with facility policy. During the annual survey, multiple areas in the dining department, kitchen, dry storage, walk-in refrigerator, freezer, pantry, dish room, and dining room were observed with food debris, sticky residue, black flaky substance, and other buildup on equipment, surfaces, floors, walls, doors, gaskets, and carts. Staff repeatedly confirmed the observations during the survey process. In the kitchen, the microwave had food debris and sticky substance on the inside and outside of the door and handle. The two-door reach-in refrigerator had black substance in the gasket grooves, dried sticky substance on the doors and bottom shelves, and an employee meal box was stored inside. Prep tables had food debris and sticky substances on the bottom shelves. The stove top drip tray had a large amount of debris, the steamer had sticky substance on top, and the double ovens had large amounts of dried sticky substance and debris on the doors, glass, sides, and heating area. The dry stock room floor had a large amount of dark black substance and food debris, and two gallons of water were sitting on the floor in front of shelving. Additional observations showed a hole in the wall near the exit door with peeling paint and loose baseboard, debris and black substance on the walk-in refrigerator fan and ceiling, a case of potatoes touching the ceiling in the walk-in refrigerator, cases of ice cream touching the ceiling in the freezer, and a case of pizza and vegetables sitting on the freezer floor. In the dining room, the countertop and backsplash had a red sticky substance, drawers and cabinets contained small dark cylindrical pellets resembling mouse droppings, food delivery carts had sticky debris and dried liquid on the outside, and a refrigerator had black sticky substance on the doors, gaskets, and bottom. A container of thickened tea was found open and undated near the hand wash sink, and food temperature logs were missing multiple meal temperatures across several days. The cabinet near the kitchen entrance, the cabinet under the coffee maker, the pantry refrigerator, the trash can at the kitchen entrance, and the dish room also had debris, sticky residue, and buildup, including black flaky substance along floorboards and debris on the dish machine and hand wash sink.
COVID-19 Vaccination Documentation and Administration Deficiencies
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document vaccination status for several residents. Record review and staff interview showed that five of seven residents screened for immunizations did not have documentation of being administered the 2024-2025 and/or 2025-2026 COVID-19 vaccines, and in some cases there was no consent or declination on file. The residents identified in the report were #37, #49, #70, #89, and #91, with the facility census listed as 120. Resident #37 had no documentation of administration, consent, or declination for the 2024-2025 or 2025-2026 COVID-19 boosters. Resident #49 had received prior COVID-19 vaccines, including the 2023-2024 SpikeVax booster, but was not offered the 2024-2025 or 2025-2026 COVID-19 immunizations. Resident #70 had last received a COVID-19 booster on 02/01/23 and had no additional consents or vaccines since that date. Resident #89’s representative consented to the 2025-2026 Nuvaxovid vaccine, but the vaccine had not been administered. Resident #91’s representative consented to the 2024-2025 COVID-19 vaccine, but it also had not been administered. The DON confirmed the missing education, offering, consent/declination, and administration issues during the survey.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure a resident's food preferences were honored and failed to implement the resident's care plan related to dietary choices. Resident #105, admitted on [DATE] and with two hospital leaves, told the surveyor that the facility gave her oatmeal and eggs every day, that she did not want these foods, and that she was lactose intolerant. The resident also stated the facility had not asked about her food preferences. When the Dietary Manager was asked to provide the resident's dietary preferences, he reported that none were on file and then visited the resident to obtain them. The resident's care plan, dated 12/16/25, stated the facility would honor her food preferences within the meal plan, but those preferences had not been obtained or documented.
Unsafe and Poorly Maintained Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, homelike environment for residents. During observation and interview, the privacy curtain in one resident’s room was missing several brackets needed to fasten it to the overhead track, causing the curtain to droop and appear as if it was about to fall off the track. In another resident’s room, the privacy curtain was observed to be dirty and covered with dark brown stains and a white substance, and the Administrator confirmed both curtain findings during the survey. Additional room environment concerns were observed in two other resident rooms. In one room, the wallpaper above the resident’s headboard had several areas that were torn and peeling, and the paint on the lower left wall was removed with visible scratches. In another room, the wallpaper above the headboard had a section missing, torn, and peeling, and the wooden base trim on the wall had several scratches that damaged the wood. The Nursing Home Administrator reviewed these observations with the surveyor and stated the facility had previously conducted an audit of building maintenance needs, but the hallway work had not yet been started.
Failure to Administer Ordered RSV Vaccinations
Penalty
Summary
The facility failed to administer the Respiratory Syncytial Virus (RSV) vaccine according to orders, resident preferences, and goals, as well as facility Policy #IC605 and CDC/ACIP guidance. Record review and staff interview showed that two of five RSV immunization records reviewed were deficient, involving two residents whose health care decision makers had already provided consent for the vaccine, yet the vaccine had not been given by the time of survey review. For one resident, consent for the RSV immunization was obtained from the health care decision maker on 01/26/26, but the resident had not received the vaccine when the record was reviewed on 02/17/26. For the second resident, consent for the RSV immunization was obtained on 07/31/25, but the resident still had not received the vaccine at the time of review on 02/17/26. When the Director of Nursing was interviewed, she agreed both residents should have received the vaccine by then and stated she did not know why it had not been administered.
Failure to Provide Ordered Orthotics for ROM
Penalty
Summary
The facility failed to ensure Resident #103 had orthotics in place for a contracture and range of motion. Record review showed the resident was supposed to have a left resting hand splint applied daily as tolerated, with staff instructed to attempt to get at least 2 fingers under the straps. The care plan noted the resident would refuse heel protectors, but it did not mention the resting hand splint. Review of care plan tasks showed no documentation that staff attempted to don the heel protectors, and multiple survey observations found the resident was not wearing any orthotics. Physical Therapy and Occupational Therapy evaluations and clinical notes made no mention of using the hand splint and instead suggested heel protectors. Two full months of task records showed the resident received no care for either splinting. The Nursing Home Administrator verified these findings during interview.
Ordered Fall-Intervention Mattress Not in Place
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards over which it had control. During a walk-through of the 500 hall, Resident #63 was found absent from the room, and the bed mattress was observed without a sheet. The mattress was identified as a standard mattress. When RN #93 was asked what type of mattress was on the bed, she stated it was a standard mattress and acknowledged that a resident ordered a defined perimeter mattress would have a mattress built up on the edges to help prevent the resident from falling out of bed. It was then confirmed that Resident #63 had a physician order for a defined perimeter mattress as a fall intervention, but that mattress was not on the bed.
Personal Refrigerators Not Monitored or Maintained
Penalty
Summary
The facility failed to maintain food items in residents’ personal refrigerators in a safe and sanitary manner, affecting five of six refrigerators observed. On 02/15/26 at 11:00 AM, surveyors observed that the refrigerators in the rooms of Residents #29, #46, #52, #75, and #98 had not had temperatures checked daily as required by the facility’s Refrigerator/Freezer Temperature Log. The report states that the facility policy required nursing to record refrigerator temperatures daily, housekeeping to clean the refrigerators inside and out, and nursing to monitor food for proper labeling and the date food was placed in the refrigerator. Further observation showed that the refrigerators were dirty and contained unlabeled and expired food items. Resident #46’s refrigerator had not had temperatures recorded since 02/02/26 and contained numerous unlabeled and expired items. Resident #52’s refrigerator had not had temperatures recorded since 02/13/26 and was extremely dirty, with a drink that had leaked and run out of the front of the refrigerator, along with numerous unlabeled and expired items. Resident #75’s refrigerator had not had temperatures recorded since 02/11/26 and contained numerous unlabeled and expired items, including two containers of potato chip dip that had expired in 05/2025. Resident #98’s refrigerator had not had temperatures recorded since 02/11/26 and was extremely dirty with numerous unlabeled and expired items. The Administrator was shown the concerns at 11:38 AM and confirmed they had not been addressed as they should.
Incomplete informed consent documentation for psychotropic medications
Penalty
Summary
The facility failed to maintain an accurate and complete medical record related to informing a resident in advance of the risks and benefits of proposed care, treatment alternatives, and the resident’s ability to choose the preferred option. This was identified for one resident who had capacity to make his or her own decisions regarding care and treatment. The resident’s record showed diagnoses of anxiety disorder, depression, and insomnia, and the resident was prescribed Sertraline HCl 50 mg daily for depression and Trazodone HCl 25 mg at bedtime for depression/insomnia. Documentation that the resident was informed of the benefits and risks of these medications was not found in the medical record. The facility provided consent forms for the medications, but the resident had not signed them. During interview, the DON stated the resident had verbally consented to receive the medications but refused to sign the forms, and a staff member who witnessed the verbal consent signed the form. The verbal consent was not co-signed and witnessed by a second party, and the DON acknowledged that a second person should have signed the verbal consent form.
Delayed Influenza Vaccination
Penalty
Summary
The facility failed to administer the influenza vaccine in a timely manner for Resident #91, despite the resident’s patient representative having consented to the vaccine on 01/26/26. On 02/17/26 at 9:30 AM, record review showed that the resident had not yet received the influenza immunization, even though the facility policy states the purpose of the immunization is to prevent the spread of influenza and its complications and to achieve the highest level of immunity during peak flu season. During the same review, the Director of Nursing confirmed that Resident #91 should have already been vaccinated and stated she did not know why the vaccine had not been given.
Failure to Address High Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan that addressed all of a resident's needs, specifically omitting interventions for fall risk. Upon admission, the resident was assessed as high risk for falls, with a documented history of one to two falls in the previous three months, disorientation at all times, chairbound status, presence of predisposing diseases, a recent change in condition, and use of medications that could increase fall risk. Despite these findings and a subsequent fall incident, the resident's care plan did not include fall risk or preventive interventions until after the fall occurred. The Director of Nursing confirmed that the care plan did not address the resident's fall risk prior to the incident.
Failure to Provide Correct Liquid Consistency for Residents
Penalty
Summary
The facility failed to provide liquids in the correct consistency to meet the individual needs of residents who were ordered nectar thickened liquids. This deficiency was observed in five residents, creating an immediate jeopardy situation due to the risk of physical harm and complications such as aspiration pneumonia. During the survey, it was noted that residents had liquids at their bedside that were not of the required nectar consistency, despite having orders for such. For instance, Resident #73 had thin water at the bedside, which was not in accordance with the nectar thickened liquid order, and was observed coughing during the interview. Staff interviews revealed inconsistencies in the preparation of thickened liquids. Nursing staff, including nurse aides and registered nurses, were using incorrect amounts of thickener for the liquids, leading to improper consistency. The directions on the thickener packets were not being followed, as staff were using one or two packets for 16-ounce cups instead of the correct amount specified for achieving nectar-like consistency. This inconsistency in preparation was confirmed by multiple staff members, including the Dietary Manager, who stated that all liquids were thickened on the floor by nursing staff using the packets of thickener.
Facility Fails to Maintain Clean and Repaired Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents in three rooms on the 400 and 500 halls. During an initial tour, several issues were identified: in one room, the blind had brown stains, the floor had a pink substance that could not be wiped up, the toilet tank lid did not fit properly, and the sink was not securely affixed to the wall. In another room, the bathroom light fixture was dislodged and covered in dust. A resident in a third room expressed dissatisfaction with decorative flowers on the wall and brown spots on the ceiling, which she had requested to be painted over for a year. Additionally, her fan and the bathroom light were covered in dust. These observations were confirmed during a subsequent tour with a Corporate Registered Nurse.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to provide accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident #10 was found to be hard of hearing, yet the MDS indicated adequate hearing ability, and no hearing assessment had been conducted since admission. Resident #99 had an implanted right subclavian port for IV access, which was not documented in the MDS. Resident #93's diagnosis of polycythemia vera, a type of blood cancer, was omitted from the MDS. Resident #79 was incorrectly noted as receiving insulin in the MDS, while the resident was actually prescribed Ozempic, a non-insulin diabetes medication. Lastly, Resident #56 was inaccurately documented as edentulous in the MDS, despite having some teeth remaining, as confirmed by a dental consultation. These inaccuracies were confirmed through staff interviews and record reviews, highlighting a failure in the facility's assessment and documentation processes. The Director of Nursing and Corporate Registered Nurse acknowledged the discrepancies, confirming that the MDS entries did not reflect the residents' actual conditions. These errors in the MDS could potentially impact the care and treatment plans for the affected residents, as accurate assessments are crucial for appropriate care planning.
Deficiencies in Care Plan Implementation and Documentation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for 12 out of 34 residents reviewed. This deficiency was evident in several areas, including the improper documentation and execution of care plans. For instance, Resident #26's care plan specified that no blood pressure or lab sticks should be taken from the right extremity, yet records showed that blood pressure was repeatedly taken from the right arm on multiple occasions. The Director of Nursing confirmed that the care plan was not being followed. Additionally, the facility did not adequately document or address residents' religious preferences and past experiences, as seen with Resident #48, whose care plan lacked information about their Baptist faith and history as a minister. Furthermore, several residents, including Residents #366, #61, #103, and #70, had food allergies that were not included in their care plans, indicating a significant oversight in addressing dietary needs and potential health risks. The facility also demonstrated a lack of proper documentation and monitoring of nutritional intake for residents experiencing significant weight loss, such as Residents #102, #12, #98, and #65. Meal intake documentation was frequently incomplete or missing, undermining the care plans' effectiveness in managing residents' nutritional status. Moreover, the care plans for Residents #99 and #93 did not address their medical diagnoses of epilepsy, cirrhosis, and polyneuropathy, further highlighting the facility's failure to develop comprehensive care plans tailored to individual resident needs.
Failure to Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise care plans for five out of 34 residents reviewed during the survey process. For Resident #31, the care plan was not updated to reflect an actual fall that occurred, despite the resident being identified as at risk for falls due to decreased mobility. The Administrator confirmed that the care plan had not been revised to address this incident. Resident #266's care plan did not reflect a physician's order for a house supplement to be administered twice daily, which was confirmed by the Director of Nursing. Resident #79's care plan inaccurately included a diagnosis of insulin-dependent diabetes, although the resident did not have a physician's order for insulin, as confirmed by a Corporate RN. Additionally, Resident #55's care plan did not include a diagnosis of major depressive disorder, which was identified in the Pre Admission Screening and Resident Review (PASRR), but not reflected in the medical diagnoses. This discrepancy was confirmed by a Corporate RN. These oversights indicate a failure to maintain accurate and up-to-date care plans for the residents involved.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to ensure that a resident, who is dependent on staff for showering, received the scheduled showers. The resident was supposed to receive two showers per week on Mondays and Thursdays. However, from September 1, 2024, to December 11, 2024, the resident only received 10 showers out of the 29 that were scheduled, with one documented refusal. This deficiency was confirmed through a review of the resident's medical records and interviews with the corporate Registered Nurse and the Director of Nursing. Additionally, the resident was supposed to receive bed baths on days when showers were not scheduled, totaling 72 bed baths during the same period. However, the resident only received 19 bed baths, with no documented refusals. The Director of Nursing confirmed that the resident was not receiving the showers and/or bed baths as scheduled, indicating a failure in providing the necessary care for activities of daily living.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide appropriate care and services to four residents, impacting their physical, mental, and psychosocial well-being. Resident #98 experienced repeated episodes of constipation without receiving the prescribed interventions, such as Milk of Magnesia, Dulcolax suppository, or Fleet Enema, despite having physician orders for these treatments. The Director of Nursing confirmed that the bowel protocol was not followed, as evidenced by the lack of documentation in the medication administration records. Resident #99, who had an indwelling Foley catheter, did not have her urinary output documented as required by her care plan, which was confirmed by the Nursing Home Administrator. Resident #89 was observed wearing a right hand splint without a corresponding physician's order, and Resident #26 had blood pressure readings taken from the right extremity despite orders and a care plan specifying not to do so. These deficiencies highlight a lack of adherence to care plans and physician orders, resulting in inadequate care for the residents involved.
Nutritional Maintenance Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure nutritional maintenance for several residents, leading to significant weight loss and incomplete documentation of meal intake. Resident #266 experienced significant weight loss and was supposed to receive house supplements twice daily. However, the Medication Administration Record (MAR) indicated that the resident did not take the supplements on numerous occasions, as confirmed by the Director of Nursing (DON). Resident #102 also experienced significant weight loss, and the care plan included monitoring meal intake and offering alternate choices. However, the documentation of meal intake was incomplete, with several meals not recorded. Corporate RN #156 confirmed the issues with documentation, indicating a lack of proper monitoring and recording of the resident's nutritional intake. Resident #98 experienced severe weight loss over six months, with incomplete documentation of meal intake. The Registered Dietician (RD) noted that the resident's meal intakes were usually between 50% to 100%, but documentation was missing for a significant number of meals. Similarly, Resident #65 experienced a downward trend in weight, with incomplete meal documentation since admission. The RD assessed the resident multiple times, noting varying meal consumption percentages, but the documentation was found to be incomplete, missing 52% of meal percentage documentation since admission.
Failure to Acknowledge and Manage Food Allergies
Penalty
Summary
The facility failed to properly acknowledge and manage food allergies for three residents, leading to a significant deficiency in care. Resident #103, who is allergic to shellfish, was served shrimp during a lunch meal, resulting in a severe allergic reaction. The resident reported symptoms such as facial swelling, itchy skin, and breathing difficulties, which previously required hospitalization. The resident provided photographic evidence of the meal served, which included shrimp in contact with other foods on the plate. Additionally, the lunch menu listed shrimp as an alternate meal option, indicating a lack of proper allergy management. Further deficiencies were noted in the documentation and communication of food allergies for other residents. Resident #70's tray card failed to list an allergy to pecans, while Resident #61's tray card inaccurately included an allergy to shellfish, which was not documented in the medical record. None of the food allergies for these residents were documented in their care plans. Interviews with the Director of Nursing (DON) and the Certified Dietary Manager (CDM) revealed a lack of clear procedures for communicating and verifying food allergies, with the DON unable to provide information on how allergies were care planned.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen investigation. Several food items, including a Ziploc bag of soup, an opened pie crust, and a trash bag of French bread loaves, were found opened, unlabeled, and undated. Additionally, serving utensils were improperly stored in a drawer with handles turned in different directions. These deficiencies were confirmed by the Certified Dietary Manager (CDM), who acknowledged the lack of proper labeling and dating, and noted that the cook preferred to keep serving utensils in the drawer. The CDM admitted that there were dates on the food items at one point, but they were no longer present.
Improper Garbage Disposal in Kitchen and Dining Areas
Penalty
Summary
The facility failed to properly dispose of garbage in accordance with professional standards for food service safety. Observations made on December 9th revealed that garbage was overflowing from a trash can located under the handwashing sink in the kitchen, with trash hanging out and onto clean pots and baking sheets in the surrounding area. Additionally, garbage from the trash can was found on the storage rack with clean pots and baking sheets. The Certified Dietary Manager (CDM) was present and questioned whether the trash can should be removed. Further observations in the dining room showed food on tables and the floor, along with dirty napkins and straws. The CDM reported that housekeeping cleans the area after dinner, and noted that breakfast was not served in the dining room. Dirty silverware was also observed on the table. The CDM picked up some of the food and trash off the floor while kitchen staff were preparing for lunch. These findings were confirmed by the CDM during the initial kitchen investigation.
Inaccurate and Incomplete Medical Records Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents during the long-term care survey. For one resident, an observation revealed multiple missing teeth, yet the most recent oral health evaluation inaccurately documented the resident as edentulous. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged the absence of a more recent dental assessment. Another resident's medical record contained a physician order indicating the resident was NPO and fed by a feeding tube, yet meal percentages were documented on multiple dates, which the DON confirmed as inaccurate. Additionally, a resident's Pre Admission Screening and Resident Review (PASRR) was coded for Major Depressive Disorder, but there was no corresponding diagnosis in the medical record or care plan. A Corporate Registered Nurse (CRN) was unable to explain the origin of this diagnosis. Furthermore, another resident's record lacked documentation of current vaccinations, and attempts to contact the Medical Power of Attorney (MPOA) were not documented, as confirmed by the Infection Preventionist Registered Nurse (IPRN).
Inaccurate and Incomplete Discharge Documentation
Penalty
Summary
The facility failed to provide accurate and timely discharge notices for a resident during transfers to an acute care facility. Specifically, the resident was discharged on three occasions, but the documentation was incomplete or incorrect for two of these transfers. On one occasion, the transfer form dated 09/25/24 incorrectly listed the transfer date as 07/19/24. Additionally, there was no transfer form completed for the discharge on 07/19/24. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of proper documentation for the resident's transfers.
Failure to Identify Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to properly identify and document mental health diagnoses for two residents in their Pre Admission Screening and Resident Review (PASARR) process. For Resident #18, the diagnoses of Bipolar Disorder and Post-Traumatic Stress Disorder (PTSD) were not identified on the most recent PASARR dated 11/14/23. This discrepancy was confirmed by the State Surveyor during a review with the Director of Nursing on 12/17/24. Similarly, for Resident #55, the PASARR did not identify Bipolar Disorder, despite the resident's medical records indicating diagnoses of Schizoaffective Disorder, Anxiety Disorder, and Bipolar Disorder. This oversight was confirmed by Corporate Registered Nurse #155 during a record review on 12/10/24.
Failure to Identify Religious Preferences in Care Plan
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, as evidenced by the lack of identification of religious preferences in the care plan for one of the residents. Specifically, a resident expressed that they were not invited to activities that aligned with their religious beliefs, such as church services, and noted that they did not participate in activities like bingo due to personal beliefs against gambling. The resident, who had a history of being a minister and identified with the Baptist faith, did not have these preferences documented in their care plan. This oversight was confirmed by the facility's Administrator during the survey process.
Failure to Evaluate Resident's Hearing Impairment
Penalty
Summary
The facility failed to evaluate a resident's hearing impairment, which was identified during a survey. The resident, who was hard of hearing, was interviewed and found to have impaired communication due to this condition. Despite the care plan acknowledging the resident's hearing impairment, the medical record lacked any documentation of a hearing test or assessment for hearing aids. The Director of Nursing confirmed that no hearing assessment had been performed since the resident's admission to the facility.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a deficiency in maintaining mobility and good foot health. During an observation, it was noted that the resident had long toenails that extended from the tip of the toes and were curled at the ends. A review of the resident's medical record revealed no diagnosis that would prevent staff from providing nail care, and there was no record of the resident having seen the facility's podiatrist. The Director of Nursing confirmed the resident's toenails were long and needed trimming, and acknowledged that the resident had not seen the podiatrist recently.
Failure to Use PPE for Resident in Enhanced-Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols by not wearing appropriate personal protective equipment (PPE) while providing care to a resident under Enhanced-Barrier Precautions (EBP). On December 12, 2024, Nurse Aide #35 was observed providing activities of daily living (ADL) care to Resident #12, who was in EBP due to wounds, a suprapubic catheter, and a feeding tube, without wearing the required gown and gloves. Additionally, Registered Nurse #102 and Licensed Practical Nurse #1 did not don PPE before performing wound care on the same resident. The EBP signage was found turned backward, making it invisible to staff entering the room, which contributed to the oversight. The Director of Nursing acknowledged the failure to wear proper PPE during ADL and wound care.
Failure to Provide Accurate Bed-Hold Information Upon Hospital Transfer
Penalty
Summary
The facility failed to provide an accurate accounting of bed-hold days to the healthcare decision maker for a resident who was discharged to an acute care hospital on three separate occasions. Record review showed that the bed-hold notices for each discharge were incomplete, containing only the nurse's signature, the resident's name, medical record number, and state abbreviation, with no information on the number of Medicaid bed-hold days available or the price per day. There was also no documentation indicating that the notice was provided to or reviewed with the resident's responsible party, nor any record of whether the responsible party wished to pay for the bed-hold or declined. The resident was receiving Medicaid services, and the Nursing Home Administrator confirmed that there was no other documentation showing the resident's son was informed of the remaining bed-hold days at the time of each discharge.
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 68 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 Hurricane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Putnam Center | 0.8 mi | ★★★★★ | 13 | 0 |
| Cabell Healthcare Center | 8.3 mi | ★★★★★ | 0 | 0 |
| Riverside Valley Of Journey | 11.7 mi | ★★★★★ | 2 | 0 |
| Valley Center | 13.8 mi | ★★★★★ | 2 | 0 |
| Dunbar Center | 14.3 mi | ★★★★★ | 4 | 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.