Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Sulphur Springs Center during CMS and state inspections, most recent first.
A resident's missing clothing was reported by a family member, but staff failed to document the grievance, investigate the loss, or follow up with the resident's representative as required by facility policy. Interviews revealed that staff did not consistently communicate or escalate the concern, and the grievance was not logged or resolved according to established procedures.
Incorrect Puree Diet Consistency Served: A resident with dysphagia and an order for puree solids with nectar-thick liquids was served ground-texture chicken instead of a pudding-like puree, and four other residents on puree also received the same incorrect meat consistency. The facility’s diet description required puree foods to be moist mashed potato or pudding consistency, and an ST noted the resident had significant swallow deficits with NPO and PEG recommended but declined by the family.
A facility failed to maintain a clean, comfortable, homelike environment. Two residents’ toilet rooms were observed in disrepair, including stained commodes, black residue, and erratic caulking. In the laundry area, a dirty fan was left on the clean side, the clean vent and ceiling were darkened, soiled laundry bags were on the floor, and floor tiles were broken or missing. Another resident reported poor bathroom lighting, and observations confirmed an out light bulb and very dim shower lighting.
Staff failed to follow menu and tray card directions by serving undersized scoops, inconsistent puree portions, and meals that did not match ordered large portions. Residents who were supposed to receive double portions instead received smaller servings, and one resident with a no-milk order was observed drinking milk despite the tray ticket stating no milk.
Food storage and preparation practices were not followed when surveyors found opened food items without dates or labels, including tortilla strips, milk, hard boiled eggs, whipped spread, apple juice, and bread in the kitchen and nourishment centers. An LPN and NPE confirmed the unlabeled items, and a Dining Director was observed preparing lunch without a beard covering until corrected by the Dining District Manager.
Infection prevention and control failed when clean socks were stored on the floor in the clean laundry area and open bags of soiled laundry were left on the floor in the soiled laundry area. In addition, a Nursing Assistant entered a resident’s room under contact precautions for C-Diff and set up the lunch tray without wearing PPE, despite posted instructions requiring gloves and gowns.
The facility failed to notify the Ombudsman of resident discharges/transfers for three of seven residents. Based on observation and staff interview, the deficiency involved required notification related to resident needs, appeal rights, or bed-hold policies.
PASARR Not Updated for New Bipolar Disorder Diagnosis. A resident’s PASARR was not updated after Bipolar Disorder was added to the diagnosis list. The DON confirmed the PASARR did not include the new diagnosis and stated a new one would be started.
A resident with limited ADL ability was not provided needed grooming assistance to remove facial hair. The resident stated he wanted to be shaved, and a CNA confirmed the facial hair and said she would get it shaved, but the resident was later still observed with facial hair and an LPN confirmed it remained.
A resident was observed with a bandage on the right arm, but the chart initially had no documentation of the skin injury or related order. The DON stated the nurse discovered skin tears after the resident scratched his arm on the bed, called the MD, and obtained an order but forgot to enter it. A later note confirmed the order for cleansing and an Optifoam dressing and documented that the nurse failed to enter the order.
A resident experienced fear and distress due to another resident's aggressive behavior, which included entering their room at night. The aggressive resident had a history of verbal and physical aggression, yet their care plan lacked documentation addressing these behaviors. The facility failed to follow its policies on behavior management and abuse prohibition, as no evaluations or interventions were implemented, and the incidents were not reported or discussed in team meetings.
A facility failed to follow a physician's recommendation for a biopsy of thyroid nodules for a resident upon readmission. The resident's healthcare surrogate was not informed, and there were inconsistencies in the documentation of the resident's capacity and treatment preferences. This led to a situation of immediate jeopardy.
A resident, not identified as an elopement risk, exited a facility undetected and was later found deceased outside. Despite being checked by a nurse shortly before the incident, no alarms were heard, and the facility's initial investigation could not determine how the resident left. Video footage was inconclusive, and staff interviews revealed no alarms were disabled. The incident highlighted a failure in monitoring and securing facility exits.
The facility allowed dietary staff to work without obtaining necessary food handler permits, as revealed during a record review and staff interview. Several employees had been working without permits for extended periods, which was acknowledged by the DSAM.
A survey identified deficiencies in food storage and preparation, including undated and exposed items in refrigerators and freezers, unsanitary kitchen equipment, and rusted microwaves used for resident meals. Additionally, inaccurate temperature logs for personal refrigerators in resident rooms were found, with discrepancies between recorded and actual temperatures.
The facility failed to properly dispose of refuse, potentially attracting vermin and affecting all residents. Observations revealed litter around dumpsters, open lids, and a leaking dumpster. The Dining Services District Manager acknowledged these issues.
The facility failed to update care plans for a resident's psychotropic medication and behaviors, another resident's surrogate change, and a third resident's weight monitoring orders. The care plans did not reflect current medical orders or surrogate decisions, leading to deficiencies in care.
A resident with a history of wandering and aggressive behavior was not properly managed, leading to safety concerns for other residents. Despite documented incidents, the facility did not follow its policies on behavior management and abuse prohibition. The DON acknowledged awareness of the behaviors but failed to take necessary actions, such as placing the resident under observation or discussing the issues in team meetings.
A resident receiving palliative care for COPD and Liver Cell Carcinoma experienced discrepancies in medication administration documentation. An RN failed to accurately log Morphine Sulphate doses on the MAR, despite signing them out on the narcotic count sheet. The RN struggled with military time and the facility's computer system, leading to multiple documentation errors. The DON and Unit Managers were informed, and the RN was suspended pending investigation.
A deficiency in infection control was observed when an NA placed a used meal tray back onto a cart with clean trays after discovering a resident was not present. This action, acknowledged as incorrect by the NA, could potentially affect all 64 residents in the facility.
A survey identified several deficiencies in a LTC facility, including cloudy window panes obstructing views, a cracked bedside table posing a hazard, dead flowers with unpleasant odors, and improper storage on a light fixture. Additionally, the facility lacked documentation of required fire drills for specific shifts. These issues were confirmed by the Administrator and staff during the survey.
A facility failed to involve a resident's appointed surrogate in medical decisions despite the resident's incapacity. The NP completed an invalid POST form and did not contact the surrogate regarding a biopsy recommendation or nutritional support suggested by the dietitian. The NP assumed the resident's preferences based on past discussions, leading to a deficiency in the resident's rights.
The facility failed to inform a resident of his right to participate in hospice care, despite his cognitive ability to make informed decisions. Additionally, another resident was administered Zyprexa without prior consent from their representative, violating the facility's policy on informed consent for psychotropic medications.
The facility failed to implement care plans for two residents, resulting in deficiencies in nutritional assistance. A resident was not monitored or assisted with her meal for over an hour, and another resident experienced weight loss without a developed nutritional care plan. Staff acknowledged these oversights during the survey.
The facility failed to address the nutritional needs of two residents. A resident's dietician-recommended nutritional support was declined by the NP without notifying the surrogate, despite the resident being incapacitated. Another resident's physician-ordered weekly weights were not conducted, as acknowledged by the DON. These actions led to inadequate nutritional support and monitoring.
A facility failed to follow a physician's order for a resident's tube feeding volume. An LPN administered 414 ml of Jevity 1.5 CAL instead of the prescribed 320 ml due to using non-graduated cups for measurement. The LPN acknowledged the lack of proper measuring tools and did not use a graduated syringe to verify the correct amount, resulting in the resident receiving more nutrition than ordered.
The facility failed to accurately report nurse staffing information, with discrepancies found in nine out of ten forms reviewed. Reported direct care staffing hours and HPPD calculations were incorrect, and data entries were incomplete. Additionally, RN staff with administrative roles were misclassified as direct care staff, contributing to the inaccuracies.
A resident with dementia, anxiety, and depression exhibited wandering, aggression, and refusal of care, yet the facility failed to update the care plan or schedule a psychological appointment. The DON admitted the resident's behaviors were not reviewed by the IDT, and no new interventions were developed.
A resident with dementia, anxiety, and depression exhibited aggressive and wandering behaviors, but the facility failed to update the care plan or involve the IDT to address these issues. Despite documented behaviors, no psychological evaluation was conducted, and the care plan lacked interventions for the resident's mental health needs.
A resident with dementia exhibited behaviors such as wandering and aggression, but the facility failed to involve the Interdisciplinary Team (IDT) to address these issues. The care plan was not updated with new interventions, and a psychological appointment was not arranged. The Director of Nursing acknowledged these oversights, which led to a deficiency in care.
A resident was administered Zyprexa 10mg IM for agitation without proper monitoring for side effects and without obtaining the necessary consent. The facility's Director of Nursing acknowledged the lack of consent and the improper handling of medication administration documentation.
A facility failed to properly administer a PRN psychotropic medication to a resident, as Zyprexa was given without a specific diagnosed condition documented. The administration lacked a specific consent form, and no monitoring occurred post-administration. The DON acknowledged the absence of consent and the need for a new disclosure form, highlighting inconsistencies in documentation and adherence to facility policies.
The facility's QAPI program failed to correctly implement procedures for managing Virginia Portable Order for Scope of Treatment (POST) forms, as identified during a survey. The facility attempted to modify POST forms, contrary to the requirement to void and replace them if changes are needed. The Administrator and Quality Assurance Committee were unaware of this requirement, and the necessary data to evaluate the QAPI program's effectiveness was unavailable due to technical issues.
The facility's QAPI committee failed to address deficiencies in POST form procedures, leading to inaccuracies in documentation. The administrator and committee were unaware of the correct process for voiding and completing new POST forms, and the Nurse Practitioner completed forms without the attending physician's capacity determination. This affected all residents, as POST forms were not accurately completed or modified.
Failure to Follow Grievance Policy for Missing Resident Clothing
Penalty
Summary
The facility failed to implement its grievance policy and procedure regarding a report of missing clothing for a resident. According to the electronic medical record, a resident's sister reported that she had brought in twelve pairs of socks, which were later found to be missing from the resident's room. Nursing staff checked with laundry, but the socks were not located, and the incident was documented. However, there was no further documentation in the medical record regarding follow-up or resolution of the missing items. Additionally, a review of the facility's grievance log revealed that no written grievance was completed for this incident. Interviews with staff indicated inconsistent understanding and execution of the grievance process. The resident's representative reported not being contacted after initially reporting the missing socks. The social worker stated she was not informed of the missing items, and the administrator acknowledged that there was no evidence of an investigation or follow-up as required by the facility's grievance policy. The policy specifies that concerns should be documented, logged, and followed up with timely communication to the person filing the grievance, none of which occurred in this case.
Incorrect Puree Diet Consistency Served
Penalty
Summary
The facility failed to ensure residents on a puree diet were served food in the correct consistency according to the facility’s diet description. During the lunch meal observation, a resident with dysphagia and an order for a regular/liberalized puree diet with nectar-thick liquids was served a tray that included puree bread, puree cinnamon apples, puree peas, and a chicken item that appeared ground rather than pureed. The Regulatory Compliance Advisor confirmed the chicken was ground and not pureed, and the Corporate Dietary Manager stated the item was supposed to be a pudding consistency but had dried out. Further review showed that five residents in the facility were on a puree diet, and the other four residents on puree also received the ground-texture chicken instead of puree. The facility’s diet description for puree consistency solids stated that all pureed foods must be the consistency of moist mashed potatoes or pudding. One resident had an AMA signed by the MPOA related to diet recommendations, and the medical record documented that the family had been informed of the risks of food that did not follow the current diet order. The Speech Therapist stated that when the resident had a modified barium swallow, significant deficits were found and NPO with a PEG tube was recommended, but the family declined. The therapist further stated that incorrect diet consistency can lead to choking and aspiration pneumonia. The deficiency was identified during the survey as affecting all five residents currently on a puree diet.
Unsafe and Unkempt Resident Areas and Laundry Conditions
Penalty
Summary
The facility failed to ensure a clean, comfortable, homelike environment for residents. In Resident #18's bathroom, the corner commode had a hole through the drywall to allow the toilet handle to function, and the base of the commode was stained yellow with a black substance around it. In Resident #3's toilet room, there was a black substance around the base of the commode with a white caulking substance erratically applied over it. During a later observation with the NHA, both toilet rooms were confirmed to be in disrepair. In the laundry area, a fan covered with a gray fuzzy substance was sitting on the floor on the clean side and was not in use, and the Laundry Director stated it should have been removed. The clean laundry vent was darkened in color, with the Laundry Director stating the discoloration was from a washer fire and that the vent and ceiling really needed to be painted. In the soiled laundry, 3-4 bags of soiled laundry were on the floor because an empty barrel was needed on the unit, and there were broken and missing floor tiles in the clean laundry. Resident #32 also reported difficulty seeing in the bathroom, and observations showed one of the two light bulbs over the sink was out and the light over the stand-up shower was very dim; a later observation showed the sink light still out and the shower light still very dim.
Incorrect Meal Portions and Tray Card Noncompliance
Penalty
Summary
The facility failed to follow its menus and dietary guide sheet by serving incorrect portion sizes and items that did not match resident tray cards and diet orders. During lunch meal observation, staff were seen plating items such as corn, mashed potatoes, rice, and fajita mix with less than full scoops and not emptying the scoops completely onto the plate, resulting in servings smaller than the facility’s stated guide sheet amounts. Pureed rice and pureed meat were also observed with inconsistent scoop sizes, including half scoops and two scoops at times, and the Administrator and Regulatory Compliance Officer confirmed the inconsistent scooping and directed staff to fill scoops to the top before serving. Several residents did not receive the large portions ordered and listed on their tray cards. One resident ordered large portions received only one piece of chicken, one dinner roll, no whipped topping on banana pudding, three half pieces of squash medley, and no milk, and a NA confirmed the resident did not receive double portions. Other residents with large portion orders did not receive the ordered 1 1/2 chicken sandwiches or the ordered double mashed potatoes, which was confirmed by nursing staff. Another resident with a tray card stating no milk was observed drinking milk, and the NA confirmed the resident had consumed the milk even though the meal ticket stated no milk; the resident’s diet order was regular/liberalized puree with no milk.
Food Storage and Preparation Not in Accordance With Standards
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the kitchen investigation, surveyors found tortilla strips opened and not dated, a carton of whole milk not dated, and hard boiled eggs opened and not labeled. The Dining District Manager stated that food storage is typically seven days for items on the floor and three days for drinks and sandwiches. Surveyors also found multiple items in the nourishment centers that were not labeled with open dates or use-by dates, including Gold 'N Sweet whipped spread in individual containers, 36 individual cups of apple juice, a loaf of bread that was opened and not sealed or labeled, and 18 additional cups of apple juice. These items were confirmed by the NPE and an LPN. In addition, the Dining Director was observed preparing and cooking quesadillas for lunch without a beard covering, and the Dining District Manager instructed the staff member to put one on.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infections. During a tour of the laundry area, a basket full of clean socks was found stored on the floor in the clean laundry area, and the Laundry Supervisor stated the socks were not stored to prevent contamination. In the soiled laundry area, three open bags of soiled laundry were observed on the floor, and the Laundry Supervisor stated they had been placed there because an empty barrel was needed on the unit; when asked if the bags were stored properly, he stated they were not. Resident #43 was observed in a room with a contact precautions sign stating the resident could not come out of the room and instructing staff to wear gloves and gowns upon entering. While the resident’s lunch tray was being delivered, a Nursing Assistant entered the room and set up the tray without putting on PPE. The DON stated the resident was on contact precautions for C-Diff and confirmed the Nursing Assistant entered the room without following the precautions. Record review confirmed the C-DIFF diagnosis and the contact precautions for the resident.
Failure to Notify Ombudsman of Discharges/Transfers
Penalty
Summary
The facility failed to ensure that the Ombudsman was notified of resident discharges/transfers. This deficiency was identified based on observation and staff interview and involved three of seven residents, including Residents #72, #71, and #68. The report states that the issue was related to required documentation or notification concerning the residents' needs, appeal rights, or bed-hold policies, and it specifically notes the failure to notify the Ombudsman of discharges/transfers.
PASARR Not Updated for New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure an updated PASARR was completed for a resident with a new diagnosis of Bipolar Disorder. Resident #11’s PASARR was reviewed on 09/03/2025 and showed it had been completed on 02/19/2025 without including Bipolar Disorder. The resident’s diagnosis list was updated on 03/12/2025 to add Bipolar Disorder, but the PASARR was not updated to reflect that new diagnosis. On 09/09/2025, the DON confirmed there was no diagnosis of Bipolar Disorder on the resident’s PASARR and stated, "I will get a new one started."
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to ensure a resident with limited ADL ability received the necessary grooming assistance to maintain facial hair removal. During the initial survey interview process, the resident was observed with facial hair and stated that he did not want it and wanted it shaved, saying, "I want it shaved" and "They need to do it." A nursing assistant confirmed the resident's facial hair growth and said she would get it shaved. When the resident was observed again several days later, he still had facial hair, and when asked if he had been shaved, he replied, "A long time ago" and "You can see it." An LPN also confirmed the resident's facial hair.
Failure to Timely Enter Physician Order for Skin Tear
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not entering physician orders timely for a resident’s skin issue. Resident #8 was observed on multiple occasions with a bandage on the right arm dated 09/01, but the medical record initially contained no mention of the bandage or the related skin injury. During interview, the DON stated that the nurse discovered skin tears after the resident scratched his arm on the bed, called the doctor, and obtained an order but forgot to enter it. A later nurse’s note documented that the resident scratched his right forearm, obtained an order to cleanse and apply an Optifoam dressing one time only, and that the nurse failed to enter the order.
Failure to Protect Residents from Abuse and Ensure Safety
Penalty
Summary
The facility failed to protect its residents from abuse, specifically failing to prevent mental or emotional harm. This deficiency was identified during a survey process where it was found that a resident, identified as Resident #42, was experiencing fear and distress due to another resident, identified as Resident #61, entering their room at night. Resident #42 reported being scared and unable to sleep because Resident #61 would come into their room, prompting the staff to place a stop sign on the door, which was ineffective as Resident #61 continued to enter the room. Resident #61's medical records revealed a history of physical and verbal aggression towards staff and other residents, including an incident where Resident #61 wandered into another resident's room, refused to leave, and attempted to hit staff and residents. Despite these behaviors, there was no documentation in Resident #61's care plan addressing their aggression, and no assessments or follow-ups were conducted for the residents affected by these behaviors. The facility's policies on behavior management and abuse prohibition were not followed, as the necessary evaluations and interventions were not implemented. The Director of Nursing (DON) was aware of Resident #61's behaviors but had not taken appropriate actions to address the situation. There was no psychological evaluation arranged for Resident #61, and the incidents were not reported or discussed in interdisciplinary team meetings or Quality Assurance and Performance Improvement (QAPI) committee meetings. The facility failed to ensure a safe environment for its residents, as no measures were taken to prevent further incidents or to address the emotional distress experienced by Resident #42.
Failure to Follow Physician's Recommendation for Biopsy
Penalty
Summary
The facility failed to follow up on a physician's recommendation for a biopsy of thyroid nodules for a resident upon readmission. The resident, who had previously expressed a preference against certain treatments, was not consulted about the referral to an ENT specialist. The healthcare surrogate, who was the resident's grandson, was not informed of the hospital's recommendation for a biopsy. This oversight was confirmed during an interview with the Director of Nursing (DON) and the Nurse Practitioner (NP), who assumed the resident would not want the procedure based on past medical decisions. The resident's capacity to make medical decisions was inconsistently documented. Three capacity forms were completed by the attending physician, with varying conclusions about the resident's capacity. One form indicated the resident had capacity, while two others stated the resident was incapacitated. These forms were not consistently dated, and there were discrepancies between the forms and the physician's notes, which further complicated the situation. Additionally, there were inconsistencies in the Physician Orders for Scope of Treatment (POST) forms. The forms showed conflicting information about the resident's preferences for treatments and emergency contacts. The resident's grandson was initially listed as the emergency contact, but later forms indicated the resident's sister as the surrogate. These inconsistencies in documentation and communication contributed to the facility's failure to follow up on the physician's recommendation, creating a situation of immediate jeopardy.
Resident Elopement and Death Due to Facility Oversight
Penalty
Summary
The facility failed to ensure a safe environment for its residents, resulting in the elopement and subsequent death of a resident. The incident involved a resident who was not identified as an elopement risk, as per an assessment conducted prior to the event. On the day of the incident, the resident was found outside the facility, unresponsive, and later pronounced deceased. The resident had been checked by a nurse approximately 35 minutes before being discovered outside, and it was determined that she had exited the facility through a door near her room. Interviews with family and staff revealed that the resident was not known to wander and typically did not leave her room without assistance. On the day of the incident, the resident exhibited unusual behavior by getting up early and expressing feelings of nausea and fatigue. Despite these signs, staff did not perceive any immediate risk, and no alarms were heard during the time the resident exited the facility. The facility's initial investigation could not determine how the resident managed to leave the building undetected, as all door alarms were reportedly functional upon inspection. Video footage from a nearby building captured a figure matching the resident's description exiting the facility, but the footage was unclear and did not provide conclusive evidence of how the resident managed to leave. Staff interviews indicated that no alarms were heard, and the facility's alarm system was checked and found to be operational. The incident highlighted a significant oversight in monitoring and securing the facility's exits, which ultimately led to the resident's elopement and death.
Failure to Ensure Dietary Staff Have Required Food Handler Permits
Penalty
Summary
The facility failed to employ qualified dietary staff by allowing employees to work in the dietary department without obtaining the necessary food handler permits. This deficiency was identified during a record review and staff interview, revealing that several employees had been working without the required permits. Specifically, one employee had been working since October 2023 without a permit, while two others had been working since April and May 2024, respectively, without permits. The Dining Services Account Manager (DSAM) acknowledged these instances and was unable to provide the permits when initially requested, indicating a lapse in compliance with regulatory requirements for food safety and staff qualifications.
Deficiencies in Food Storage, Preparation, and Temperature Monitoring
Penalty
Summary
The facility was found to have several deficiencies related to food storage and preparation during a survey. In the kitchen's walk-in refrigerator, there were multiple items such as trays of cake, a container of beef base, and strawberries that were either undated or exposed to the elements. Additionally, a box of squash was past its discard date. Similar issues were found in the walk-in freezer, where chicken breasts were undated, and bags of frozen corn and biscuits were left open. The reach-in refrigerator contained items like barbeque sauce and hard-cooked eggs that were past their discard dates. A dietary aide confirmed these issues, attributing them to staff from other centers who did not adhere to proper dating protocols. The kitchen's oven was also found to be unsanitary, with burnt food and debris present inside. A staff member acknowledged that the oven should have been cleaned but cited a lack of available staff to perform the task. Furthermore, the nourishment rooms for different units had microwaves with rust and missing parts, which were still being used to prepare food for residents. The Dining Services Account Manager confirmed the condition of the microwaves and the ongoing attempts to replace them. The facility also failed to maintain accurate temperature logs for personal refrigerators in resident rooms. The logs showed a pattern of identical temperatures and times, suggesting inaccuracies. During a review, it was discovered that some refrigerators lacked thermometers, and the recorded temperatures did not match the actual temperatures observed. The administrator acknowledged these discrepancies, indicating a failure to properly monitor and document refrigerator temperatures as per the facility's policy.
Improper Disposal of Refuse
Penalty
Summary
The facility failed to properly dispose of refuse, which could potentially attract vermin and affect all residents. During a tour of the rear of the facility, it was observed that the area around the dumpsters was littered with an empty potato chip bag, multiple clear gloves, pieces of food, and clear plastic garbage bags. Additionally, three out of four dumpsters had their lids open, with one missing a lid entirely. One of the dumpsters was leaking a white substance onto the pavement. The Dining Services District Manager acknowledged the trash on the ground and the condition of the dumpsters.
Failure to Update Care Plans for Medications and Surrogates
Penalty
Summary
The facility failed to review and revise the care plan for a resident's psychotropic medication, dementia, and behaviors. The resident was prescribed medications such as Ativan and Lexapro for anxiety and depression, but the care plan did not reflect the use of Lexapro or the one-time administration of Zyprexa. Additionally, the resident's behaviors, including wandering and aggression, were not adequately addressed in the care plan, and there was no evidence of monitoring for adverse reactions following the administration of Zyprexa. The facility also failed to update the care plan for another resident to reflect the change in the health care surrogate. The resident's care plan initially listed the sister as the surrogate, but a checklist indicated that the sister was no longer reachable, and the grandson was appointed as the new surrogate. Despite this change, the care plan was not revised to reflect the new surrogate. Furthermore, the care plan for a third resident was not updated to reflect the physician's order and the surrogate's request for no weights to be obtained. The resident's care plan included monitoring for changes in nutritional status but did not address the specific order for no weights. This oversight indicates a failure to align the care plan with the resident's current medical orders and surrogate's wishes.
Failure to Address Aggressive Resident Behavior
Penalty
Summary
The facility failed to provide medically related social services for a resident who exhibited aggressive behaviors and for other residents affected by these behaviors. Resident #61 was noted to have a history of wandering into other residents' rooms and displaying physical and verbal aggression. Despite these behaviors being documented in the medical record, there was no corresponding care plan addressing these issues. The facility's policies on behavior management and abuse prohibition were not followed, as the interdisciplinary team did not assess the underlying causes of Resident #61's behaviors, nor was there any follow-up or intervention to address the aggressive incidents. Resident #42 reported feeling scared due to Resident #61 entering their room at night, which affected their sleep. Despite this, there was no evidence of any assessment or follow-up by social services to address the impact of these incidents on Resident #42 or other residents. The Director of Nursing (DON) acknowledged awareness of Resident #61's behaviors but admitted that no actions were taken to ensure the safety and well-being of other residents. The facility also failed to report the incident from 07/06/24, as required by their policies. Interviews with the DON, social worker, and assistant director of nursing revealed a lack of communication and coordination in addressing Resident #61's behaviors. The facility did not place Resident #61 under one-on-one observation following the incident, nor did they discuss the behaviors in interdisciplinary team meetings or quality assurance and performance improvement committee meetings. This lack of action and oversight contributed to the deficiency in providing necessary social services and ensuring a safe environment for all residents.
Medication Administration Documentation Errors
Penalty
Summary
The facility failed to accurately document medication administration times on the Medication Administration Record (MAR) and the narcotic count sheet for a resident receiving Morphine Sulphate. The resident, who was admitted with Chronic Obstructive Pulmonary Disease (COPD) and Liver Cell Carcinoma, was under palliative care. During a review, discrepancies were found between the narcotic count sheet and the MAR, indicating that several doses of Morphine Sulphate were signed out by a registered nurse (RN) but not documented as administered on the MAR. The discrepancies included multiple instances where the RN signed out doses of Morphine Sulphate but failed to document the administration on the MAR. The RN admitted to struggling with military time and the facility's computer system, which contributed to the documentation errors. Despite previous training and ongoing assistance from the facility, the RN continued to have issues with accurately logging medication administration times. The facility's Director of Nursing (DON) and Unit Managers were made aware of the discrepancies, and it was confirmed that the RN had forgotten to log several doses in the MAR. The RN was subsequently suspended pending further investigation. The report highlights the failure to maintain accurate medication records, which is a critical aspect of resident care and safety.
Infection Control Breach During Lunch Service
Penalty
Summary
During a lunch service observation in the 400 hallway of the facility, a deficiency in infection control practices was identified. Nurse Aide (NA) #10 removed a meal tray from the delivery cart and took it to a resident's room, only to find that the resident was not present. NA #10 then returned the tray to the cart with the clean, undelivered trays, which is a breach of proper infection control protocols. NA #10 acknowledged the mistake and expressed uncertainty about why the tray was placed back on the cart. This incident has the potential to affect all residents in the facility, which has a census of 64.
Environmental and Safety Deficiencies Identified in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents, staff, and the public, as observed during a long-term care survey. Several issues were identified, including cloudy and moisture-trapped window panes in various locations, such as the exit doors to the courtyard and the front entry door, which obstructed visibility. Additionally, a bedside table in room 305 A was found with large cracks and exposed sharp edges, posing a skin tear hazard. Dead flowers with cloudy water and an unpleasant odor were found in rooms 304 and 307, and items were improperly stored on top of an over-the-bed light fixture in room 305 B, creating a potential hazard. Furthermore, the facility lacked documentation of required fire drills, specifically for the 3rd shift of the 2nd quarter of 2024 and the 2nd shift of the 3rd quarter of 2023. These deficiencies were confirmed through interviews with the facility's Administrator and other staff members, who acknowledged the issues during the survey process. The absence of fire drill records and the environmental concerns identified during the survey have the potential to affect all residents within the facility.
Failure to Involve Resident Representative in Medical Decisions
Penalty
Summary
The facility failed to involve the appointed resident representative in medical decision-making for a resident who lacked capacity. The resident, identified as having a Brief Interview for Mental Status (BIMS) score of 06, was deemed incapacitated by the attending physician. Despite this, the Nurse Practitioner (NP) completed a Physician Orders for Scope of Treatment (POST) form with the resident, which was later acknowledged as invalid due to the resident's incapacity. The NP did not contact the resident's appointed surrogate, the grandson, regarding a physician's recommendation for a biopsy of thyroid nodules, believing the resident would refuse the procedure based on previous discussions. Additionally, the facility did not consult the surrogate regarding nutritional support recommendations made by the Registered Dietitian. The resident, who had a significant weight loss and various medical conditions, was recommended to receive house shakes twice daily for nutritional support. The NP declined this recommendation, citing the resident's comfort care status and previous refusals of treatment. The NP did not consider alternative nutritional supplements and did not inform the surrogate of the dietitian's recommendations. Interviews with the NP and Director of Nursing (DON) confirmed that the surrogate was not contacted for either the biopsy referral or the nutritional support recommendation. The NP admitted to not being aware of the physician's note regarding the resident's incapacity and acknowledged that the POST form completed was invalid. The failure to involve the surrogate in these decisions resulted in a deficiency in the resident's right to have their representative exercise their rights.
Failure to Inform Residents of Care Decisions
Penalty
Summary
The facility failed to inform Resident #28 of his right to participate in hospice care, which is a significant aspect of end-of-life decision-making. Resident #28, who was diagnosed with Chronic Obstructive Pulmonary Disease and Liver Cell Carcinoma, was cognitively intact with a BIMS score of 14, indicating he had the capacity to make informed decisions. Despite being marked for end-of-life care, the Nurse Practitioner (NP) did not discuss hospice options with him, stating a personal belief that hospice services were unnecessary. This omission occurred even though the NP acknowledged that residents have the right to participate in their care decisions. Additionally, the facility failed to notify the responsible party for Resident #61 about the potential side effects of a psychotropic medication before its administration. Resident #61 was administered Zyprexa intramuscularly for agitation and restlessness without obtaining prior consent from the resident's representative. The facility's policy required that consent be obtained and documented before administering such medications. However, the Director of Nursing (DON) confirmed that no consent was obtained for Zyprexa, and the necessary documentation was not completed. These deficiencies highlight the facility's failure to ensure residents are fully informed and able to participate in their care decisions. Both residents were affected by the facility's lack of adherence to policies regarding informed consent and participation in care planning, which are critical components of resident rights in long-term care settings.
Failure to Implement Nutritional Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in nutritional assistance. Resident #7's care plan was not followed, as she was not monitored or assisted with her meal for over an hour after it was delivered. The surveyor observed that Resident #7's lunch tray, delivered at 12:00 PM, remained uneaten by 1:05 PM. The resident's hands appeared constricted, and she was unable to feed herself. A Registered Nurse acknowledged that staff should have checked on her, and a Certified Nurse Aide later assisted her with a new meal tray. Resident #61 did not have a nutritional care plan developed despite experiencing weight loss. A review of Resident #61's medical record showed a physician's order for weekly weights and a diet order, but no dietary care plan was present. The Director of Nursing confirmed the absence of a dietary care plan for Resident #61, acknowledging the oversight.
Failure to Address Nutritional Needs and Follow Physician Orders
Penalty
Summary
The facility failed to adequately address the nutritional and hydration needs of residents, specifically for two residents identified during the survey. For Resident #29, the facility did not follow the Registered Dietician's recommendation for nutritional support through house shakes twice daily. The Nurse Practitioner (NP) declined this recommendation, citing the resident's comfort care status and previous refusal to address gallbladder issues. The NP did not notify the surrogate decision-maker about the dietician's recommendation, despite the resident being deemed incapacitated by the attending physician. The NP acknowledged that the POST form completed was invalid due to the resident's incapacity and agreed that the surrogate should have been contacted. For Resident #61, the facility failed to adhere to a physician's order for weekly weights, which was part of the resident's care plan. The medical record review showed missing weights, and the Director of Nursing (DON) acknowledged that the order had not been followed. This oversight indicates a lapse in monitoring the resident's nutritional status, which is critical for maintaining their health. These deficiencies highlight the facility's failure to implement and communicate necessary dietary interventions and to follow physician orders for monitoring residents' health. The lack of communication with surrogates and failure to adhere to care plans contributed to the inadequate nutritional support for the residents involved.
Failure to Follow Physician's Order for Tube Feeding Volume
Penalty
Summary
The facility failed to adhere to the physician's order regarding the volume of feeding to be administered to a resident with a feeding tube. The physician's order specified that the resident should receive 320 ml of Jevity 1.5 CAL five times per day, with specific instructions for flushing the tube with water before and after each feeding. However, during an observation, an LPN was seen preparing the feeding using two 7-ounce non-graduated plastic cups, which were not accurate for measuring the prescribed amount. The LPN admitted to using these cups based on a previous measurement with a manager, which was not precise, leading to the administration of 414 ml instead of the ordered 320 ml. The LPN acknowledged the discrepancy and the lack of proper measuring tools, such as graduated cups or cylinders, which contributed to the error. Despite recognizing the issue, the LPN proceeded to administer the feeding without using a graduated syringe to ensure the correct volume was given. This resulted in the resident receiving more nutrition than prescribed, highlighting a failure in following the physician's order and ensuring accurate measurement of feeding volumes.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to accurately complete the Nurse staffing information, resulting in discrepancies between reported and actual direct care staffing hours. This issue was identified during a long-term care survey process, where nine out of ten Nurse Staffing forms reviewed contained inaccuracies. The discrepancies involved incorrect total direct care staffing hours and hours per patient day (HPPD) calculations, as well as incomplete data entries for certain shifts. On several occasions, the facility's Daily Staffing forms reported incorrect total direct care staffing hours compared to the actual hours recorded in the Genstar daily staffing sheet and time detail. For instance, on one date, the reported total direct care staffing hours were 148, while the actual hours were 164.65, leading to an incorrect HPPD calculation. Similar discrepancies were found on other dates, with reported hours either overestimated or underestimated compared to the actual hours worked by the staff. Additionally, the facility failed to accurately categorize staff roles according to the Centers for Medicare & Medicaid Services (CMS) guidelines. The Daily Staffing forms incorrectly included RN staff with administrative roles as direct care staff, without distinguishing between their administrative and direct care duties. This misclassification contributed to the inaccuracies in the reported staffing hours, as the facility could not identify how these RN staff members allocated their time between administrative and direct care tasks.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and psychiatric services to a resident, identified as Resident #61, who exhibited behaviors such as wandering, refusal of care, and physical and verbal aggression. The resident's medical record indicated multiple instances of these behaviors, including an incident where the resident wandered into other residents' rooms and refused to leave, showing aggression towards staff and other residents. Despite these documented behaviors, the facility did not have an updated care plan addressing the resident's anxiety, depression, or specific behaviors. The care plan had not been revised since its creation, and there was no evidence of a psychological appointment being scheduled for the resident. Interviews with the Director of Nursing (DON) revealed that the resident's behaviors had not been reviewed by the Interdisciplinary Team (IDT) committee for root cause analysis or for the development of new behavioral interventions. The DON acknowledged the lack of review and care plan revisions. Additionally, when questioned about scheduling a psychological appointment for the resident, the DON admitted that no such appointment had been made and expressed uncertainty about the reason for this oversight. The facility's inaction in addressing the resident's behavioral health needs and failure to update the care plan contributed to the deficiency.
Failure to Provide Individualized Care for Resident with Mental Disorders
Penalty
Summary
The facility failed to provide necessary person-centered care and individualized treatment for a resident diagnosed with mental disorders and psychosocial adjustment difficulties. The resident exhibited behaviors such as physical and verbal aggression, wandering into other residents' rooms, tearfulness, and refusal of care. Despite these behaviors being documented in the resident's medical record, there was no corresponding care plan addressing these issues, nor were there any revisions made to the existing care plan to accommodate the resident's changing needs. The resident's medical history included diagnoses of unspecified dementia with behavioral disturbances, generalized anxiety disorder, and major depressive disorder. The resident's care plan only addressed the risk of delirium related to dementia, with no interventions for anxiety, depression, or the specific behaviors observed. The facility's policy required that residents exhibiting behavioral symptoms be evaluated by the Interdisciplinary Team (IDT) to identify underlying causes and develop appropriate interventions, but this process was not followed for the resident in question. Interviews with the Director of Nursing (DON) revealed that the resident's behaviors had not been reviewed by the IDT, and no psychological appointment had been made for the resident. The DON acknowledged the lack of care plan revisions and the absence of a psychological evaluation, indicating a failure to provide the necessary treatment and services to meet the resident's mental and psychosocial needs.
Failure to Provide Interdisciplinary Care for Dementia
Penalty
Summary
The facility failed to provide an interdisciplinary approach to address the needs of a resident diagnosed with dementia, leading to a deficiency in care. The resident exhibited behaviors such as wandering into other residents' rooms, refusal of care, and physical and verbal aggression. Despite these behaviors being documented, the facility did not involve the Interdisciplinary Team (IDT) to identify the underlying causes or update the care plan with new behavioral interventions. The Director of Nursing (DON) acknowledged that the resident's behaviors had not been reviewed by the IDT committee, and the care plan had not been revised accordingly. Additionally, the facility did not arrange a psychological appointment for the resident, which could have been beneficial in managing the resident's condition. The resident's care plan included goals and interventions for managing mood symptoms related to dementia and Parkinson's, but the facility did not implement individualized, person-centered, non-pharmacological interventions as the initial strategy for behavior mitigation, as stated in their policy. The lack of a comprehensive approach and failure to update the care plan contributed to the deficiency in providing necessary services for the resident's dementia diagnosis.
Failure to Monitor and Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to monitor a resident for side effects after administering a psychotropic medication, Zyprexa 10mg IM, for agitation. The resident, identified as having restlessness and poor safety awareness, was given the medication following a change in condition evaluation. However, the facility did not document any monitoring of the resident's condition post-administration, which is a critical step in ensuring the resident's safety and well-being. Additionally, the facility did not obtain the necessary consent for the administration of Zyprexa. The Director of Nursing acknowledged that no consent was obtained prior to administering the medication, and a new form for Psychotropic Medication Administration Disclosure should have been completed. The existing forms only documented consent for other medications, and the addition of Lexapro to an existing form was improperly handled. This oversight in obtaining and documenting consent represents a significant deficiency in the facility's medication management process.
Failure to Administer PRN Psychotropic Medication Properly
Penalty
Summary
The facility failed to properly administer a PRN psychotropic medication for a resident diagnosed with a specific condition. On a particular date, the resident exhibited signs of agitation and restlessness, prompting the administration of Zyprexa 10 mg IM without a specific diagnosed condition documented in the clinical record. The medical record review revealed that the administration of the medication was not accompanied by a documented consent form specific to Zyprexa, as required by the facility's policy. The Director of Nursing acknowledged that no consent was obtained prior to the administration and that a new Psychotropic Medication Administration Disclosure form should have been completed. Additionally, the facility did not conduct any monitoring of the resident after the administration of Zyprexa IM. The review of the resident's medical record showed inconsistencies in the documentation of verbal consent for psychotropic medications, with different medications listed on two separate forms. The Director of Nursing admitted that a new form should have been completed instead of adding medications to an existing form. The lack of proper documentation and monitoring highlights the facility's failure to adhere to its own policies regarding the administration of psychotropic medications.
Deficiency in POST Form Management
Penalty
Summary
The facility failed to properly implement its Quality Assurance and Performance Improvement (QAPI) program concerning the completion of Virginia Portable Order for Scope of Treatment (POST) forms. During a survey, it was identified that the facility was attempting to modify POST forms, which is not permissible according to the form's instructions. The correct procedure requires voiding the existing form and completing a new one if changes are necessary. The facility's QAPI program, which was intended to address issues with POST form completions, did not account for this requirement, leading to a deficiency in the process. The Administrator acknowledged that the Quality Assurance Committee (QAC) was unaware of the correct procedure for handling POST forms, including the necessity to void and replace forms rather than modify them. The deficiency was further compounded by the lack of data available to demonstrate the effectiveness of the QAPI program, as the Administrator's computer, which contained the relevant data, was not operable. This oversight has the potential to affect all residents who require POST forms, as the facility's current practices do not align with the established guidelines for managing these documents.
Deficiency in POST Form Procedures and QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to develop effective corrective actions to address deficiencies in the completion and modification of POST forms. During a survey, it was discovered that POST forms were being modified instead of voided and replaced as required. The facility's administrator and QAPI committee were unaware of the proper procedures for voiding and completing new POST forms, which led to inaccuracies in the documentation. Additionally, the Nurse Practitioner was completing POST forms without the attending physician's determination of capacity, which was not known to the administrator or the QAPI committee. The deficiency affected all residents, as the POST forms were not accurately completed or modified based on the physician's determination of capacity. The administrator acknowledged missing pertinent details in the QAPI process and audits related to POST form completions and corrections. The facility's failure to adhere to the correct procedures for POST forms and the lack of awareness among the staff and QAPI committee contributed to the deficiency identified during the survey.
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 34 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 White Sulphur Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seneca Trail Healthcare Center | 12 mi | ★★★★★ | 18 | 0 |
| Lewisburg Healthcare Center | 12.7 mi | ★★★★★ | 11 | 1 |
| Brian Center Of Alleghany | 20.6 mi | ★★★★★ | 0 | 0 |
| The Springs Nursing & Rehab Center | 24.3 mi | ★★★★★ | 0 | 0 |
| The Woodlands Health And Rehab Center | 24.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for White Sulphur Springs Center.
100% money-back within 48 hours.
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.