Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Center during CMS and state inspections, most recent first.
Improper storage and disposal of garbage and refuse was observed when one exterior dumpster door was left open without staff present and a dining room trash can lid was found on the floor during kitchen observation. The HCSG DM also noted that the two trash cans outside the dish room were soiled and that no cleaning schedule was posted at the time.
Surveyors found that staff failed to timely notify resident representatives of significant changes in condition and events. In one case, a resident without decision-making capacity had worsening back pain, but only the resident was informed and the HCS was not notified. In another case, a resident who fell had an MPOA listed along with an alternate contact, yet only one unsuccessful attempt was made and the alternate was not contacted. A third resident experienced behavioral changes leading to a straight cath urine collection, and the POA was notified only after the procedure; the same resident later had a fall where the physician was notified that evening but the POA was not informed until the next morning. The DON acknowledged that these notifications were not completed or not done in a timely manner per policy.
Surveyors identified multiple failures to keep the environment free of hazards and to follow safe transfer and fall-prevention practices. Hazardous bleach wipes were left within reach at a bedside, loose drywall and debris were present in a bathroom and in dining room cabinets accessible to residents, and a topical medication was left at a bedside for self-use despite the resident not being care planned to self-administer. One resident care planned as dependent on a mechanical lift with two staff was repeatedly transferred to the toilet via wheelchair with one staff and no lift, while the resident reported staff often refused to assist to the bathroom and directed use of briefs or a bedpan instead. Another resident designated as a gait belt transfer was moved from bed to wheelchair by a NA without a gait belt, a resident care planned for a low bed with a fall mat had the bed left above the lowest position, and a resident assessed for total lift transfers had a bedside commode in the room despite the DON stating such residents should not have one.
Failure to maintain dignity during toileting, catheter care, and dining: a resident reported staff would not take her to the bathroom despite her ability to use a wheelchair and bathroom bars, while records showed she was taken to the toilet by wheelchair without the documented mechanical lift. During observed catheter care, an NA did not close the privacy curtain, and during lunch service another resident’s bedside commode was left open with bloody stool visible while the meal tray was in the room.
Unsafe and Poorly Maintained Resident Rooms and Bathrooms: Surveyors found multiple resident rooms and TCU bathrooms with peeling paint, unfinished drywall, loose caulking, leaking sinks, black substance at the base of toilets, urine odors, burnt-out lights, missing fixtures, and loose or falling tiles. RN and DON interviews confirmed the conditions, and the Administrator acknowledged the unresolved repairs.
Failure to Follow and Update Individualized Care Plans: Multiple residents had care plans that were not followed or were incomplete. A resident repeatedly received bed baths instead of scheduled showers, another remained on an unchanged antipsychotic dose despite an approved GDR, and several residents had transfer, fall, fracture, or bathing preference needs that were not reflected in care delivery or documentation. Staff observations and record review showed transfers done without the ordered lift or gait belt, a bed not kept in the lowest position despite a fall precaution, and missing documentation of fractures and shower preferences.
A resident’s ordered antibiotic was delayed after a positive urine culture and ongoing dysuria. Another resident had a critical blood glucose reading that was not reported to the physician per protocol. A third resident had open, bleeding thigh wounds with no documented wound assessment or treatment for days, and a fourth resident had long fingernails and scratches behind the ear with no documented assessment or monitoring.
Food and drink were not served in a palatable, attractive, and safe temperature. Based on tray temperature checks, resident interviews, and staff interviews, the facility failed to ensure hot foods were served hot. This issue was identified on all three meal trays tested during the survey process, including trays for two residents.
Unsanitary food storage, equipment, and cart handling were observed throughout the kitchen and dining areas. Staff found soiled food service equipment, dirty beverage and meal carts, improperly stored food items, cleaning cloths not kept in sanitizer, and a resident fruit container left partially open in the refrigerator. Two employees also entered the kitchen without hairnets, and the DON acknowledged several of the sanitation issues.
Infection control practices were not maintained during resident care, linen transport, and housekeeping observations. A nurse aide completed catheter care for a resident and then continued assisting the resident while still wearing soiled gloves without hand hygiene. Clean linen was observed being transported on an uncovered cart, shower rooms contained unclean surfaces and soiled items, and multiple resident wheelchairs and Geri-chairs had tears, holes, and exposed padding. One resident’s room also contained full urinals on the floor and a soiled bedside commode.
Failure to Obtain Informed Consent for Psychotropic Medications: Two residents had psychotropic medication orders without the proper informed consent in the record. One resident had Buspirone started without documented consent before initiation, and another resident had an Olanzapine order, but the only consent provided was for Lexapro. The DON confirmed the missing or mismatched consent documentation.
Call Lights Not Kept Within Reach: Two residents had call lights out of reach, including one placed across the bed on the resident’s paralyzed side and another found on the floor. Staff confirmed the call lights were not within reach, despite the facility policy requiring call lights to be kept within reach and secured as needed.
A resident’s bathing preference for showers was not honored when she was only given bed baths after her usual CNA was no longer working. The care plan showed a shower preference, the bathing record showed no shower refusals, and the resident and her son stated she had not been asked about a shower since the change. The DON confirmed the documentation showed she had not been offered a shower.
A resident remained on a higher-than-approved dose of olanzapine after the MD signed off on a GDR recommended by the consulting pharmacist. The MAR was never updated, so the resident continued receiving the original antipsychotic dose for 14 days; the DON said it was overlooked, and the Administrator acknowledged the excessive dosing.
The facility failed to ensure the MDS accurately reflected the condition of two residents. One resident's MDS showed ambulation and omitted fractures, even though PT records and the PTA indicated the resident could not walk and had metatarsal fractures. Another resident's MDS listed walking 10 feet with supervision, but PT records and the PTA stated the resident had not walked in years; the Administrator confirmed the MDS was inaccurate.
A resident with a diagnosis of Psychoactive Substance Abuse had a PASARR that did not identify that diagnosis. Record review showed the diagnosis in the chart, and the Social Worker agreed it should have been included on the PASARR.
A resident had physician-ordered oxygen therapy and incentive spirometer use, but the baseline care plan did not include any focus, goals, or interventions for oxygen therapy. Record review showed the ordered monitoring and oxygen at 2 L/min via NC for SOB, and the missing care plan elements were confirmed with the Corporate RN and DON.
A resident’s care plan was not revised to reflect his nighttime care preference after an allegation of neglect involving incontinence care at night. Staff later stated the resident did not want to be awakened between 10 PM and 6 AM, but the resident could not clearly confirm that this intervention matched his preference and said he usually sleeps through the night and lets staff know if he needs help.
Failure to provide needed ADL hygiene and bathing care for two residents. One resident was observed with a dirty face, neck, and hands, soiled bedding, long untrimmed fingernails, and scratches behind the ear, while the resident’s wife reported she had to clean him and trim his nails. Another resident stated he had gone several days without a shower, and records showed only one bed bath with no refusals despite a shower schedule and a care plan for extensive assist with bathing.
A resident was observed with no water at the bedside, and an LPN confirmed that fluids were not present at the time of the surveyor's observation. There was no evidence that fluids had been recently offered or were readily accessible to the resident.
A resident receiving HD did not have ongoing assessment documented before, during, and after treatment because required dialysis communication records were not completed by the dialysis center on multiple occasions. The DON and Administrator confirmed the missing records should have been reviewed when the resident returned and completed by the nurse.
A facility failed to serve foods consistent with Dys Adv diet orders for two residents. One resident was observed with whole grapes and another with whole orange slices, even though the dietary guidelines called for modified textures for this diet. The observations were confirmed with the DM.
A resident was not offered or served lunch even though the resident was in the room when the meal was being passed. The surveyor found the tray still on the cart with a torn ticket, while CNA and activities staff stated they did not offer the tray or tear the ticket. The DON confirmed the resident did not receive lunch, and the Administrator stated this was neglect.
A resident reported pain shortly after a nurse documented a pain score of 0 and gave Tylenol, but there was no documented follow-up pain reassessment after the resident said, "I am in pain" and "My legs are hurting." The MAR also showed Ativan ordered for sublingual use was administered orally instead of by the ordered route, and the NP later clarified the intended route as PO.
A resident with Alzheimer's disease experienced two significant changes in condition, including elevated heart rate and altered mental status with multiple symptoms, but the facility did not notify the resident's representative as required by policy. The DON and Administrator confirmed that notification should have occurred.
The facility was found to have medicated items and personal hygiene products left accessible in resident rooms, posing potential hazards to wandering residents. Items such as hydrogen peroxide, anti-fungal powder, and oral pain relief rinse were not properly labeled or stored, as confirmed by the DON and CRN.
The facility failed to ensure residents received treatment and care according to professional standards, care plans, and resident choices. Issues included unavailable medication, undocumented insulin administration, and discrepancies in advanced directive orders, affecting multiple residents.
The facility failed to ensure a safe environment by leaving a resident's medication unattended and having multiple instances of unlocked and unattended medication and treatment carts. These lapses in supervision and security were observed by surveyors and confirmed by staff.
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during an annual survey. Both residents had signed the Notice of Medicare Non-Coverage (NOMNC) but did not receive the SNF ABN form, placing them at risk of not being informed of their rights and potential liability for services not covered by Medicare.
The facility failed to report an alleged incident of verbal abuse to the appropriate state agencies. A nurse informed a resident about her need for a shower due to an odor in front of other residents, which was perceived as humiliating. The incident was investigated internally but not reported as required by the facility's Abuse Prohibition Policy.
The facility failed to ensure accurate MDS assessments for three residents, including significant weight loss for one resident and incorrect discharge statuses for two others. These inaccuracies were acknowledged by the facility's Administrator.
The facility failed to complete new PASARRs for three residents with newly evident or possible serious mental disorders, including delusional disorder, Bipolar disorder, and PTSD. The oversight was confirmed by staff during interviews.
The facility failed to update the care plans for two residents when their needs changed. One resident's care plan did not include her delusional disorder diagnosis, and another resident's care plan did not address her significant pain management needs or her goals for pain relief, despite her worsening condition and recent changes in pharmacological interventions.
The facility failed to evaluate and document the effectiveness of pain medication for two residents. An LPN signed out and administered oxycodone but did not document its effectiveness, as confirmed by the Clinical Operation Lead.
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were reviewed and signed by the attending physician. For a resident, the pharmacist recommended reassessment of the A1C goal and potential initiation of Januvia, but there was no evidence that the physician reviewed or acted on this recommendation, as the MRR was not signed.
The facility failed to obtain routine and/or emergency dental services for a resident who had a loose tooth. Despite an active order for a dental referral, no referral had been made, as confirmed by the Interim Director of Nursing.
The facility failed to maintain appropriate infection control procedures during a medication pass for a resident. An LPN was observed removing pills from a blister pack with ungloved hands after touching the medication cart doors and over-the-counter pill bottles with bare hands. The administrator was informed and expressed surprise, acknowledging that handling pills with soiled bare hands was against common-sense practices.
Improper Storage and Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to store and dispose of garbage and refuse properly. During observation, one of the three dumpsters located outside the facility had one sliding door open without any employee present. In a separate observation of the kitchen, the lid for a trash can in the dining room was found sitting on the floor instead of on the container. The report also noted that the two trash cans outside the dish room were soiled, and the cleaning schedule was not posted at the time of the observation.
Failure to Timely Notify Resident Representatives of Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives in a timely manner when there was a change in condition, as required by the facility’s “Change in Condition: Notification of” policy. For one resident who lacked medical decision-making capacity, documentation showed a change in condition with worsening lower back pain, and only the resident was notified while the designated Health Care Surrogate (HCS) was not informed. For another resident with a fall, the Change in Condition form documented an attempt to contact the Medical Power of Attorney (MPOA) without success, but there was no documented attempt to contact the alternate MPOA/emergency contact listed in the resident’s profile. A third resident experienced multiple events where the Power of Attorney (POA) was not notified in a timely manner. In one instance, a change in condition with behavioral symptoms led to a urine specimen being obtained via straight catheterization; documentation showed the POA was notified after the procedure had already been completed, and the resident’s son reported he had been present earlier that day and was not informed at that time. In another instance, the same resident had a fall, and while the physician was notified the same evening, documentation showed the POA was not notified until the following morning. In each case, the DON confirmed that the notifications to the MPOA/POA/HCS were either not made or not made in a timely manner according to the documentation and facility policy.
Failure to Maintain Safe Environment and Follow Transfer and Fall-Prevention Protocols
Penalty
Summary
The deficiency involves multiple failures to maintain an environment free of accident hazards and to provide adequate supervision and safe practices to prevent accidents. In one room, a container of bleach cleaning wipes was left unattended and within reach at a resident’s bedside, with no measures in place at the time to prevent resident access. In another room, loose drywall above a bathroom sink was observed with chunks and pieces falling into the sink, and this condition remained unrepaired on recheck several days later. A resident was also found with a medicine cup containing a white creamy substance identified as Bio-Freeze left on the bedside table, even though the resident was not care planned to self-administer medications. Additional environmental hazards were identified in the Transitional Care Unit dining room, where sheet rock chunks approximately 1/2 inch in size, sawdust piles, and small wood splinters were present in all lower kitchen cabinets to the right and left of the sink and in the island cabinets, all easily accessible to residents. Several deficiencies related to unsafe transfer practices and toileting were also documented. One resident’s lift transfer evaluation and care plan specified dependence on a mechanical lift with two staff for transfers and toileting, yet documentation showed that over a one-month period the resident was assisted to the toilet via wheelchair with one staff and without use of the mechanical lift. The resident reported that most staff would not assist with transfers to the bathroom and instead told the resident to use a brief or bedpan, despite the resident’s stated ability to transfer with assistance and use grab bars. Other transfer-related deficiencies included an observed transfer where a nurse aide assisted a resident from bed to wheelchair by holding under the resident’s arm and pivoting the resident into the wheelchair without using a gait belt, even though the resident was designated as a gait belt transfer. Another resident who was care planned for fall prevention with a fall mat at the bedside and the bed in the lowest position was observed with the fall mat in place but the bed not in the lowest position. For a different resident, a lift assessment required use of a total lift with full body sling for transfers, yet a bedside commode was present in the room, and the DON stated that a resident using a total lift should not have a bedside commode in the room. These observations collectively demonstrate failures to follow established safety measures, care plans, and transfer requirements intended to prevent accidents and falls.
Failure to Maintain Resident Dignity During Toileting, Catheter Care, and Dining
Penalty
Summary
The facility failed to ensure a dignified experience with toileting for Resident #3. The resident stated staff would not take her to the bathroom and told her to use a brief or bedpan, even though she said she could use a wheelchair and the bars in the bathroom and could not have a bowel movement in a brief. A lift transfer evaluation dated 01/27/26 identified the resident as dependent for transfers using a mechanical lift with two staff members, and the care plan included toileting interventions reflecting that status. However, the tasks record from 03/03/26 through 04/02/26 showed the resident was assisted to the toilet via wheelchair on 10 occasions with staff assistance x1 and without use of the mechanical lift. After surveyor intervention, the DON completed a lift transfer assessment and the resident demonstrated a stand-pivot transfer with a gait belt. The facility also failed to provide privacy during catheter care for Resident #29. During observed catheter care, the nurse aide did not pull the privacy curtain before providing care, and the resident’s bed was closest to the bedroom door. The South Unit Manager, DON, and Administrator were notified and confirmed the curtain should have been closed before the care was provided. In addition, the facility failed to maintain dignity during dining for Resident #17 when the resident’s lunch tray was placed in the room while the bedside commode beside the bed remained open and contained bloody stool. The Administrator confirmed the bedside commode should have been emptied before lunch or the lid closed while the resident was eating to promote dignity.
Unsafe and Poorly Maintained Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 17 of 71 resident rooms observed during the survey process, including rooms 119, 120, 121, 124, 125, 126, 201, 204, 205, 206, 207, 209, 210, 212, 213, and 305. In room 119, surveyors observed peeling paint above the sink on the right wall, plastic pipes, unfinished drywall patches, and loose caulking around the sink. During interview, RN #46 acknowledged the condition of the room and stated she would report it to maintenance for repairs. The DON later stated he had been made aware of the issues in the room, and the Administrator also acknowledged that the drywall, sink caulking, and pipe had not been completely repaired yet. During a tour of the Transitional Care Unit with the DON, all bathrooms appeared dirty, dingy, and dark. Surveyors observed multiple room bathrooms with unfinished sheet rock, black substance at the base of toilets or commodes, urine odors, leaking sinks, loose or falling tiles, missing toilet paper holders, burnt-out light bulbs, a constantly running commode, and sinks needing replacement. Specific findings included leaking water onto the bathroom floor and through the wall to the corridor, baseboards pulling away from the wall, and ceiling damage in one room. The Administrator was notified of the issues, and the DON confirmed the findings were correct during the tour.
Failure to Follow and Update Individualized Care Plans
Penalty
Summary
The facility failed to develop and/or implement care plans for multiple residents, including transfer status, fall precautions, fractures, shower preferences, and a gradual dose reduction (GDR) for psychotropic medication. The report identified deficiencies for seven of 39 residents reviewed, including residents #3, #29, #7, #31, #96, #87, and #46. The findings were based on observation, record review, resident interview, and staff interview. Resident #87’s care plan specified showers on Tuesdays and Fridays, but ADL documentation showed the resident repeatedly received bed baths instead of the scheduled showers on most days reviewed. Showers were documented only on a few dates, while bed baths were documented on many others, showing the established bathing schedule was not consistently followed. The DON acknowledged the discrepancy between the care plan and the care provided. Resident #46 had a physician order for Olanzapine 5 mg at bedtime, and the consulting pharmacist recommended a GDR that the attending physician approved and signed on 03/20/2026, with the new order to be Olanzapine 2.5 mg at bedtime. The March 2026 MAR showed the order was never updated, and the resident continued to receive 5 mg. Resident #3’s record showed a lift transfer evaluation indicating dependence for transfers using a mechanical lift with two staff, yet toileting documentation showed the resident was assisted to the toilet by wheelchair on multiple occasions with one staff and without the lift. Resident #29 was observed being transferred from bed to wheelchair without the required gait belt, and staff confirmed the gait belt should have been used. Resident #7 had a fall mat at the bedside, but the bed was not in the lowest position as required by the care plan. Resident #31’s care plan did not mention her fractures, and Resident #96’s care plan stated he preferred showers, but bathing documentation showed he was not offered a shower for several days with no refusals documented.
Delayed Antibiotic Start, Unreported Critical Blood Sugar, Untreated Wounds, and Inadequate Hygiene Care
Penalty
Summary
Resident #14 had a urine culture and sensitivity resulted on 12/24/25 showing greater than 100,000 colonies of E. coli after the resident had recently complained of dysuria that continued at the time of the nurse practitioner follow-up. The nurse practitioner ordered Bactrim DS 1 tablet orally every 12 hours for 5 days on 12/24/25, but the medication order was not entered into the medical record until 12/26/25 and the first dose was not administered until 12/26/25 at 9:00 PM. The DON confirmed there was a delay in starting the ordered antibiotic and could not explain why it was not started when ordered. Resident #12 had a blood glucose fingerstick of 413 mg/dL on 03/06/2026 at 12:00 PM, which exceeded the facility’s critical threshold for hyperglycemia. The record contained no documented evidence that the physician was notified, and there were no documented new orders or clinical interventions in response to the elevated result, despite facility protocol requiring physician notification for blood glucose readings greater than 400 mg/dL. Resident #48 was observed with multiple open, circular areas on the right outer thigh with redness and active bleeding, and the resident stated, "I can't do this again tonight," yet the record showed no documented wound assessment, treatment, or wound care from that observation through the following week. Resident #87 was observed with long, untrimmed fingernails and visible scratches behind the right ear with redness and superficial skin breakdown, and follow-up observation showed the scratches remained present with no documented wound assessment, treatment, or monitoring after the initial finding.
Food Served at Improper Temperature
Penalty
Summary
Food and drink were not served in a palatable, attractive, and safe temperature. Based on food tray temperatures, resident interviews, and staff interviews, the facility failed to ensure hot foods were served hot. This deficient practice was identified on three of three meal trays tested throughout the survey process, and residents #99 and #60 were identified in the report.
Unsanitary food storage, equipment, and cart handling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, and failed to maintain proper sanitation practices for the kitchen and food preparation equipment. During an initial walkthrough of the kitchen, the Healthcare Services Group District Manager acknowledged multiple unsanitary conditions, including a soiled can opener, a toaster crumb tray needing cleaning, a dirty exhaust hood, food debris and grease buildup on the stove top, dust buildup on the juice machine, a broken ice scoop holder cover, a soiled ice scoop holder, black buildup on the dish room wall, and several pantry and refrigerator areas that needed cleaning. The walk-in refrigerator temperature was also not recorded for one evening shift. During lunch observation, beverage carts in the North hall, TCU hall, and South hall were found with wet nesting tumblers and visible food particles and debris. The North hall cart was removed from service after staff observed the wet tumblers and soiled cart, and the TCU hall cart was also sent back after the Administrator acknowledged the issue. The South hall cart was observed to be visibly soiled with food particles and debris, and staff verified that it had been sent that way. Additional observations found two opened loaves of bread and one package of hamburger buns not dated, two cleaning cloths not stored in sanitizer, a soiled trash can lid on the floor, a soiled and uncovered popcorn maker in the south dining room, and resident meal trays sent down the hallway on a soiled black cart. The facility also failed to ensure that all employees entering the kitchen had their hair properly restrained. Two unidentified activity employees entered the kitchen without hairnets. In the North Pantry/Nourishment room, a plastic container of fruit was observed on the top shelf of the refrigerator with the lid partially open, exposing the fruit to air. An employee later acknowledged the opened lid, and the DON stated the fruit belonged to a resident and had been removed from the refrigerator and replaced for the resident.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain an infection control program to prevent communicable diseases during multiple observed care and housekeeping situations. On 03/31/26, Resident #7’s room contained two full urinals on the floor at the bedside, a brown-like substance on the floor in multiple locations near the bedside commode, and the bedside commode itself was soiled with the same substance. These findings were observed and confirmed by Nurse #16 at the time of observation. Additional observations on 03/31/26 found multiple infection control concerns involving resident equipment and shared items throughout the facility. Resident #9’s wheelchair had ripped and split plastic arm covers exposing the inner padding, Resident #42’s wheelchair had cracks in the back rest with exposed padding, and Resident #46’s wheelchair had a hole in the seat with exposed padding. Multiple wheelchairs and Geri-chairs in the halls were also observed with holes, tears, and exposed padding, including a Geri-chair outside a room, a Geri-chair in the exit hallway to the courtyard, a wheelchair outside Room 301, and a wheelchair near the North courtyard door. Other observations showed improper linen handling and unclean treatment areas. A Manager-In-Training was observed pushing an uncovered clean linen cart, and the Administrator confirmed clean linen should be covered during transport. The North shower room contained an open conditioner and body wash bottle spilling onto a wet, unclean floor, personal items, and a soiled washcloth on a shower bed. The South shower room contained dried brown substance, band aids, a bloody bandage, a broken shampoo bottle top, and soiled washcloths. Resident #29’s catheter care was observed, and after care was completed, the nurse aide did not remove soiled gloves or perform hand hygiene before assisting the resident with dressing, transfer, and wheelchair movement.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for psychotropic medications for two residents reviewed. For Resident #12, the clinical record showed a physician order for Buspirone HCl 5 mg, one tablet by mouth, with documentation that the medication was initiated on 03/01/26, but there was no documented evidence that informed consent had been obtained before the medication was started. This was confirmed with the DON on 04/01/26 at approximately 3:45 PM. For Resident #46, the record showed a physician order for Olanzapine ODT 5 mg, one tablet by mouth at bedtime for antipsychotic use. When the surveyor requested the consent form, the DON provided a consent dated 09/18/2025 for Lexapro, and stated that this was the only consent available for the resident.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for dependent residents. Resident #19 was observed sitting in a wheelchair with the call light placed on the opposite side of the bed, across from the resident and on the resident’s paralyzed side, leaving it out of reach. Resident #47 was observed with the call light on the floor, also out of reach. The facility’s policy stated that staff will ensure the call light is within reach of the patient and secured as needed.
Resident’s Shower Preference Not Honored
Penalty
Summary
The facility failed to honor Resident #49’s bathing choices by not providing the resident’s preferred showers from 03/23/26 through 03/31/26. Resident #49’s care plan dated 02/03/26 stated a preference for showers, and the March bathing task record showed the resident received showers twice per week from 03/01/26 through 03/22/26 by CNA #15. After 03/22/26, the record showed only bed baths, with no documented refusals of showers during that time. During an interview on 03/31/26 at 10:02 AM, Resident #49 and her son stated the resident only gets showers when NA #15 is working and had not been asked if she wanted a shower since 03/22/26. The DON confirmed that, according to documentation, Resident #49 had not been offered a shower since 03/22/26.
Unnecessary Antipsychotic Dose Continued After Approved GDR
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when a physician-approved gradual dose reduction (GDR) for olanzapine was not carried out. Resident #46 had an order for olanzapine 5 mg at bedtime for antipsychotic use, and on 03/20/2026 the consulting pharmacist recommended a GDR to 2.5 mg. The attending physician agreed to and signed off on the reduction the same day, but the medication order in the MAR was never updated. As a result, Resident #46 continued to receive olanzapine 5 mg at bedtime for 14 days after the GDR was approved, with doses documented from 03/20/2026 through 04/02/2026. During interviews, the DON stated the change was overlooked, and the Administrator acknowledged that the resident received an excessive dose of the antipsychotic medication for fourteen days. The resident was later sent to the ER on 04/03/2026 and remained out of the facility at the time of the report.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the MDS accurately reflected residents' current condition for two sampled residents. For Resident #31, the significant change MDS listed Section GG as ambulating 10 feet with supervision, but a PT discharge summary stated the resident could stand in parallel bars without moving and was unable to take steps at that time. A PTA later stated the resident had not been able to walk since the fractures occurred. The same MDS also did not have the fractures item checked in Section I, even though the resident's diagnosis list included fourth and fifth metatarsal fractures; the DON confirmed the MDS was inaccurate and did not include fractures in the diagnoses. For Resident #57, the MDS listed the resident as able to walk 10 feet with supervision, but the last PT discharge record listed walking 10 feet as not applicable, and a PTA stated the resident had not walked in the three years he had worked at the facility. The Administrator confirmed the resident's MDS was inaccurate.
PASARR Did Not Include Documented Diagnosis
Penalty
Summary
The facility failed to coordinate with the appropriate State-designated authority when completing and revising a PASARR for Resident #66, who had a diagnosis of Psychoactive Substance Abuse. Record review showed that the PASARR dated 04/01/26 did not identify this diagnosis, even though it was documented in the resident’s medical record. The deficiency was confirmed with the Social Worker on 04/02/26, who agreed that the additional medical diagnosis should have been included on the PASARR.
Baseline Care Plan Missing for Ordered Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan for Resident #29 related to oxygen therapy ordered by the physician. On 06/03/26, the resident’s medical record was reviewed and showed orders for an incentive spirometer to be encouraged as often as tolerated each day shift, with pre-treatment evaluation of heart rate, respiratory rate, pulse oximetry, and lung sounds in supplementary documentation, and oxygen at 2 L/min via nasal cannula every shift for shortness of breath. Review of the resident’s baseline care plan showed no focus, goals, or interventions listed for oxygen therapy. This was confirmed during review with Corporate RN #19 and the DON, and the federal regulatory guidelines for a baseline care plan were reviewed with them.
Failure to Update Care Plan for Nighttime Care Preference
Penalty
Summary
The facility failed to develop and revise Resident #24’s care plan to reflect the resident’s preference for nighttime care. During record review, a facility-reported incident dated 12/08/25 was reviewed and noted an allegation of neglect related to incontinence care at night. The resident was interviewed and stated he did not remember the allegation but believed it must have happened if he said it. The Social Services Director was asked whether there was evidence the allegation of neglect was verified, and the Administrator later stated that the resident did not want to be awakened between 10:00 PM and 6:00 AM and would use the call light to request care. A revised care plan was then provided indicating the resident did not want to be awakened during those hours, but when interviewed again, the resident stated he usually sleeps through the night, wears CPAP, and lets staff know if he needs help, and he was unable to clarify whether the added intervention was truly his preference.
Failure to Provide Needed ADL Hygiene and Bathing Care
Penalty
Summary
The facility failed to ensure necessary ADL care, including personal hygiene and grooming, for two sampled residents. For one resident, the wife reported observing a dirty face, neck, and hands, soiled bedding, long and untrimmed fingernails, and scratches behind the right ear that she attributed to scratching. She stated that she trimmed the resident’s fingernails, cleaned his face and neck, and requested staff help to change his shirt and bedding. On observation with the DON, scratches behind the resident’s right ear were confirmed, and the DON acknowledged the findings. For another resident, the resident stated he had not had a shower in five or six days. The care plan called for extensive assist x1 for bathing, and bathing documentation showed only one bed bath during the relevant period with no refusals documented. The resident was on a shower schedule for Tuesdays and Fridays, and the Administrator confirmed the resident did not receive a shower during the stated period and that the care plan indicated he preferred showers.
No Water at Bedside for Resident
Penalty
Summary
The facility failed to ensure access to fluids at bedside for one resident, Resident #77, during a random observation. On 03/31/2026 at 3:07 PM, the resident's room was observed and no water was present at the bedside. At approximately 3:15 PM, LPN #16 reviewed the observation and confirmed that no water was present at the bedside at the time of the surveyor's observation. The report states there was no evidence that fluids had been recently offered or were readily accessible to the resident.
Incomplete Dialysis Communication and Post-Treatment Assessment
Penalty
Summary
The facility failed to ensure ongoing assessment of Resident #17’s condition before, during, and after dialysis treatment. A policy titled Dialysis: Hemodialysis (HD)-Communication and Documentation required the dialysis facility to return communication after HD and required a licensed nurse to review the communication, evaluate and observe the patient, complete the post-hemodialysis treatment evaluation, notify the dialysis facility if the information was not returned, and document that notification. Review of the Hemodialysis Communication Records for the past three months showed that the dialysis center did not complete records for 01/03/26, 02/04/26, 02/23/26, and 03/27/26. During an interview, the DON and Administrator confirmed that the dialysis records were not completed on those dates and should have been reviewed upon the resident’s return and completed by the nurse at that time.
Inappropriate Food Consistency for Residents on Dysphagia Advanced Diets
Penalty
Summary
The facility failed to ensure that residents received foods prepared in a form consistent with their prescribed Dysphagia Advanced diets. During dining observation, Resident #114 was served whole grapes despite a Dys Adv diet order, and the facility's dietary guidelines indicated that foods for this diet should be provided in an appropriate consistency such as applesauce or other modified textures. On another observation, Resident #110 was served whole orange slices while also ordered a Dysphagia Advanced diet, even though the dietary guidelines indicated fruits should be modified or chopped for this diet. In both instances, the surveyor intervened and the observations were confirmed with the Dietary Manager.
Failure to Provide Lunch to a Resident
Penalty
Summary
The facility failed to ensure Resident #49 received lunch, despite the resident being in the room at the time of the meal. At 12:43 PM, a surveyor observed Resident #49's son in the room and he stated that no one had come to offer lunch to the resident. At 12:45 PM, CNA #86 confirmed the aides were finished passing trays on that hall, and the surveyor later found the resident's lunch tray on the cart with the ticket torn, indicating a refusal of the tray. However, CNA #86, Activities Assistant #153, and Activities Assistant #154 all stated they did not offer the resident the tray and did not tear the ticket. The DON confirmed at 1:02 PM that Resident #49 was not offered and did not receive lunch, and the Administrator later confirmed this was considered neglect.
Inaccurate pain assessment and medication route documentation
Penalty
Summary
The facility failed to ensure accurate pain assessment, timely reassessment, administration of medications in accordance with physician orders, and maintenance of an accurate medical record for one resident. During an observation at approximately 10:30 PM, the resident stated, "I am in pain" and "My legs are hurting." The clinical record showed that a nurse administered Tylenol 325 mg orally at 10:24 PM and documented a pain assessment at that time with the resident's pain level recorded as zero, which was not consistent with the resident's later verbal reports of pain. There was no documented evidence that a follow-up pain assessment or reassessment was completed after the resident voiced complaints of pain. In addition, physician orders indicated Ativan 1 mg was prescribed for sublingual administration, but the medication administration record showed it was given orally rather than sublingually. The nurse practitioner clarified that the intended route should have been Ativan 1 mg by mouth, and this clarification was confirmed with the DON.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of two significant changes in the resident's condition. According to interviews and record review, the resident, who had been determined by a physician to lack capacity due to Alzheimer's disease, experienced two separate incidents: one involving an elevated pulse/heart rate while resting, and another involving altered mental status, weakness, shortness of breath, nausea, vomiting, and lethargy. In both cases, the resident remained in the facility and was treated in-house by on-call physicians, but the representative was not informed of these events. The resident's representative reported not being contacted by the facility regarding either incident and expressed distress over the lack of communication. Review of facility policy confirmed that the representative should have been notified immediately of significant changes in the resident's physical or mental status. The Director of Nursing and the Administrator acknowledged that the notifications should have occurred.
Unsafe Storage of Medicated Items in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, as evidenced by the presence of medicated items left accessible to residents with wandering tendencies. During a complaint survey, it was observed that various rooms contained medical items and personal hygiene products that were not labeled or stored securely, making them easily accessible to wandering residents. Specifically, items such as hydrogen peroxide, anti-fungal powder, no-rinse foam cleanser, and oral pain relief rinse were found in residents' rooms without proper identification or secure storage. The survey identified that 25 residents had wandering tendencies, and the facility census was 121. The presence of these items posed potential risks, as indicated by the Safety Data Sheets (SDS) and Material Safety Data Sheets (MSDS) provided by the Director of Nursing (DON), which outlined hazards such as eye irritation, inhalation risks, and ingestion dangers. During an interview, the Corporate Registered Nurse (CRN) confirmed that medicinal items should not be present in residents' rooms, highlighting a lapse in the facility's supervision and safety protocols.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices. Resident #49's medication, Tizanidine HCl 2 mg tablet, was not available for three consecutive days, and the LPN was instructed to hold the medication until it arrived from the pharmacy. The Director of Nursing (DON) acknowledged the issue, attributing it to pharmacy staffing problems and logistical delays. Resident #33 did not receive insulin as ordered for elevated blood sugar levels. The Medication Administration Record (MAR) showed a blood sugar level of 435, but there was no documentation that insulin had been administered. The interim DON confirmed that the MAR did not reflect any medication being given. Additionally, the facility failed to follow the Physician Orders for Scope of Treatment (POST) forms for Resident #125, who had a DNR order that was not followed, and for Resident #26, whose physician orders for skin integrity and fracture stability were not adhered to. The facility also had discrepancies in advanced directive orders for Resident #71 and Resident #44, where the orders did not match the POST forms. Resident #71 had conflicting physician orders for advanced directives, and the care plan was not updated to reflect the correct order. Similarly, Resident #44 had an active physician's order for CPR and other interventions that did not match the POST form. These failures had the potential to affect more than a limited number of residents, as indicated by the facility census of 129.
Unattended and Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards, as evidenced by multiple observations of unattended and unsecured medication and treatment carts. On 04/08/24, a surveyor observed a Spiriva inhaler left unattended on a resident's over-the-bed table. The resident confirmed that the nurse had left it there in the morning, and the charge nurse verified that the medication should not have been left at the bedside. The resident had an order for the inhaler but did not have an order for it to be left at the bedside, indicating a lapse in proper medication management. Additionally, on 04/15/24, a surveyor found an unlocked and unattended medication cart on the 300 Hall. The LPN responsible for the cart acknowledged the issue and locked it upon the surveyor's request. Similarly, on 04/09/24, a treatment cart was observed unlocked and unattended by the South Nurses Station. The LPN responsible for the treatment cart also locked it after being notified by the surveyor. These incidents demonstrate a pattern of inadequate supervision and failure to secure medication and treatment carts, posing potential risks to residents.
Failure to Provide SNF ABN Forms
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during an annual survey. Resident #28 began Medicare Part A skilled services on 10/18/23, with the last covered day being 11/10/23. Although the Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 11/08/23, there was no evidence that a SNF ABN form had been provided and signed. Similarly, Resident #19 began Medicare Part A skilled services on 02/20/24, with the last covered day being 03/21/24. The NOMNC was signed and dated on 03/19/24, but again, there was no evidence that a SNF ABN form had been provided and signed. In an interview conducted on 04/10/24, the Administrator acknowledged the facility's failure to provide the SNF ABN forms to both residents prior to their last covered day of Medicare Part A skilled services. This oversight placed the residents at risk of not being informed of their rights and potential liability for services not covered by Medicare. The review of the Form Instructions for the SNF ABN Form CMS-10055 (2018) indicated that Medicare requires these forms to be issued to beneficiaries prior to providing care that Medicare may not pay for because it is either not medically reasonable and necessary or considered custodial.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the appropriate state agencies. The incident occurred when a nurse informed a resident about her need for a shower due to an odor in front of other residents, which was perceived as humiliating and derogatory. The resident reported the incident to the Nursing Home Administrator (NHA), who, along with the Director of Nursing (DON), investigated the grievance and re-educated the nurse involved. However, the incident was not identified as verbal abuse and was not reported to the state agencies as required by the facility's Abuse Prohibition Policy. The incident was corroborated by another resident who witnessed the event and described it as embarrassing and derogatory. The facility's grievance log and state reportable log were reviewed, revealing that the incident was documented but not reported as verbal abuse. The Administrator confirmed that the incident had not been reported to the state agencies, explaining that the specific words indicating verbal abuse were not used during the initial report. This failure to report the incident as verbal abuse constitutes a deficiency in the facility's compliance with state regulations.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. Resident #116 experienced a significant weight loss of 12.5% over 3.5 months, which was not accurately reflected in the MDS. The Registered Dietician (RD) incorrectly marked the weight loss section based on a misunderstanding that weight loss should not be recorded if the resident had not been in the facility for six months. This resulted in an inaccurate assessment of the resident's nutritional status and potential care needs. Additionally, the facility inaccurately coded the discharge status for two other residents. Resident #126 was discharged home, but the MDS incorrectly indicated a discharge to a short-term general hospital. Similarly, Resident #124 was transferred to the emergency room due to clinical acuity, but the MDS incorrectly coded the discharge status as home/community. These inaccuracies were acknowledged by the facility's Administrator during interviews, highlighting a failure in the proper completion and review of MDS assessments.
Failure to Complete New PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents with newly evident or possible serious mental disorders. This deficiency was identified for three out of seven residents reviewed under the PASARR category during the Long-Term Care Survey Process. Resident #44 had a diagnosis of delusional disorder added on 04/21/20, but the facility did not complete a new PASARR upon the resident's readmission from hospitalization. Additionally, the care plan for Resident #44 was not revised to reflect the changes. The Social Worker acknowledged the oversight during an interview on 04/10/24. Resident #49 was admitted with a Bipolar diagnosis effective from 09/09/21, but the only PASARR on file was dated 11/20/2018, which did not address the Bipolar diagnosis. The Social Worker confirmed the absence of a new PASARR for this diagnosis. Similarly, Resident #81's PASARR did not include diagnoses of Bipolar disorder or Post-Traumatic Stress Disorder (PTSD), despite these conditions being present. The Administrator and Social Worker confirmed the missing information during interviews conducted on 04/09/24.
Failure to Revise Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to revise the care plans for two residents when their needs changed. Resident #44's care plan was not updated to include her diagnosis of delusional disorder, which was added to her medical record on 04/21/20. The Social Worker acknowledged that the PASRR was incorrect and had not been completed prior to the resident's readmission from hospitalization, and the care plan had not been revised to reflect these changes. Resident #71's care plan did not address her pain management needs, despite her reporting significant pain and a recent change in her pharmacological pain interventions. The care plan also failed to include her goals for pain relief and did not reflect her worsening condition, including a diagnosis of cancer with a chest mass and lymph node involvement. During an interview, Resident #71 rated her pain as 10/10 and expressed that her pain goal was 0/10, but these details were not incorporated into her care plan. The Clinical Reimbursement Coordinator acknowledged that the care plan had not been updated or revised to reflect the resident's goals and recent changes.
Failure to Document Pain Medication Effectiveness
Penalty
Summary
The facility failed to effectively evaluate the pain level and the effectiveness of pain medication for two residents. For one resident, a Licensed Practical Nurse (LPN) signed out an oxycodone tablet and documented its administration on the Medication Administration Record (MAR). However, there was no documentation showing the effectiveness of the pain medication. This was confirmed by the Clinical Operation Lead (COL). The failure to document the effectiveness of the pain medication was noted during a record review and confirmed by staff.
Failure to Ensure Physician Review of Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were reviewed and signed by the attending physician. This deficiency was identified for one of five residents reviewed during the Long-Term Care Survey Process. Specifically, for Resident #6, the pharmacist completed an MRR on 12/26/23, recommending reassessment of the existing A1C goal and potential initiation of Januvia 25 mg daily, with close monitoring of glucose levels. However, there was no evidence that the attending physician reviewed or acted on this recommendation, as the MRR was not signed by the physician. This was confirmed during a staff interview with the Clinical Operation Lead on 04/15/24.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to obtain routine and/or emergency dental services for Resident #75. During an interview, the resident indicated she had a loose tooth. A record review revealed an active order dated 02/07/24 for a dental referral for a loose cap on the upper front tooth, but no referral had been made. The Interim Director of Nursing confirmed that there was no dental referral in the resident's chart.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to maintain appropriate infection control procedures during a medication pass for Resident #49. During an observation, an LPN was seen removing pills from a blister pack with ungloved hands after touching the medication cart doors and over-the-counter pill bottles with bare hands. The medications involved were Gabapentin 100 mg capsule, Lisinopril 2.5 mg tablet, and Oyster Shell 500/200 mg tablet. The administrator was informed of the issue and expressed surprise, indicating that the LPN had reported the medication pass went well and acknowledged that handling pills with soiled bare hands was against common-sense practices.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 126 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Charleston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Valley Of Journey | 2.2 mi | ★★★★★ | 2 | 0 |
| Dunbar Center | 2.4 mi | ★★★★★ | 18 | 1 |
| Thomas Hospitals Skilled Nursing Unit | 6.3 mi | ★★★★★ | 0 | 0 |
| Arthur B Hodges Center, The | 6.4 mi | ★★★★★ | 0 | 0 |
| Complete Care At Oak Ridge Llc | 7.5 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 August 2026) and official state health department websites.