Shenandoah Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charles Town, West Virginia.
- Location
- 50 Mulberry Tree Street, Charles Town, West Virginia 25414
- CMS Provider Number
- 515167
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Shenandoah Center during CMS and state inspections, most recent first.
A resident exhibited repeated behavioral issues, including entering other residents' rooms, consuming their food and drinks, and public urination, which were observed and documented by staff. Despite these ongoing behaviors and the need for frequent redirection, the care plan was not updated to reflect or address these concerns.
A facility failed to provide safe dialysis care for a resident by repeatedly taking blood pressure in the arm with an AV fistula, contrary to medical orders. The facility also neglected to perform post-dialysis assessments, as required. Observations showed a lack of signage to alert staff about the restricted limb, and staff interviews confirmed non-compliance with care plans, leading to immediate jeopardy.
Two incidents of abuse and neglect occurred in a LTC facility. An LPN physically abused a resident during a combative episode, while a NA neglected another resident by leaving them in a soiled state. Both incidents were substantiated, and the staff involved were terminated. However, there was no evidence of preventive measures taken for the neglect incident.
A resident in a long-term care facility was mistakenly given 25 units of insulin despite not being diabetic or having an insulin order. The error occurred after a room change, and the nurse failed to verify the resident's identity. The resident's blood sugar was monitored following the incident, but the facility did not document any investigation or corrective measures to prevent future errors. Interviews revealed that the LPN involved was unaware of the room change and did not verify the resident's identity.
The facility failed to provide showers and timely transfers according to residents' preferences and care plans. Several residents reported not receiving showers for over thirty days, despite being scheduled for them. A resident experienced psychosocial harm due to a delay in being transferred from her chair to her bed, causing distress. Records showed inconsistencies in bathing schedules, highlighting a systemic issue in meeting residents' needs.
The facility failed to maintain proper infection control practices, including improper disposal of soiled linen and gloves, inadequate use of PPE in EBP rooms, and improper handling of meal trays and bedpans. These deficiencies were observed by surveyors and confirmed through staff interviews, indicating a potential risk to the facility's residents.
The facility failed to honor the bathing preferences of several residents, with some not receiving showers for over a month despite being scheduled for twice-weekly showers. Residents expressed dissatisfaction, and records confirmed significant gaps in bathing schedules. The DON acknowledged the issue and stated efforts were underway to address it.
A facility failed to keep residents' medical information confidential when an LPN left a computer unattended on a medication cart with resident information visible. The LPN later acknowledged the oversight, and the DON confirmed that the computer should have been locked.
The facility failed to maintain a homelike environment, with multiple resident doors showing visible cracks and rough edges, and a PTAC unit in a resident's room covered in moldlike substance. The resident expressed concerns about allergies, potentially linked to the mold, which was confirmed by the Maintenance Supervisor.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and personal care needs. A resident's care plan did not include a diagnosis of Dementia, while another's lacked interventions for anxiety disorder. Additionally, several residents reported not receiving showers as per their preferences, and a resident's care plan intervention to avoid taking blood pressure in a specific arm was not followed.
The facility failed to maintain a safe environment by leaving a treatment cart unlocked and unattended in a resident TV room, and unsecured medication at a resident's bedside. An RN confirmed these items should not have been left accessible to residents, unauthorized persons, or visitors.
The facility did not conduct yearly performance evaluations for three Nurse Aides, as identified during a survey. A review of records showed missing evaluations for these aides, and the Administrator confirmed the oversight, acknowledging the need to address the issue.
A facility failed to monitor behavior and side effects for a resident prescribed Lorazepam for anxiety. The resident's MAR showed no monitoring from December 2023 to May 2024, despite instructions to observe for sedation, morning hangover, ataxia, and nausea. The DON confirmed the lack of monitoring during an interview.
A survey found that a facility failed to maintain complete temperature logs for its medication refrigerator from March to July 2024. The facility's policy requires twice-daily temperature checks, but numerous dates were missing records. The Administrator confirmed the logs were incomplete, potentially affecting the care of residents.
The facility failed to discard expired food items, including scalloped potatoes and moldy onions, found in the kitchen's walk-in refrigerator. The Dietary Manager in Training acknowledged the oversight and stated they would dispose of the items. This deficiency had the potential to affect more than a limited number of residents.
The facility failed to maintain a functioning resident call system, as observed during a tour of the 200 and 300 halls where the call light system was turned off and the volume was too low. The Maintenance Assistant confirmed the system was turned off by staff, and the Maintenance Director noted that all call systems had been turned down since his employment began.
The facility failed to notify the State ombudsman of a discharge for a resident. A record review revealed that the resident had been discharged to another facility, but there was no evidence of the required notification being sent. The Administrator confirmed the absence of the notification.
The facility failed to accurately complete MDS assessments for two residents regarding their discharge destinations. One resident was discharged to another LTC facility, but the MDS listed home as the destination. Another resident was discharged to home, but the MDS recorded a short-term general hospital as the destination. These errors were confirmed by the Administrator.
A facility failed to update a resident's care plan when the status of her pressure ulcer changed. The care plan inaccurately listed the ulcer as a Stage 2, despite a skin and wound evaluation indicating it was unstageable. The DON acknowledged ongoing issues with care plan revisions.
A facility failed to provide an adequate activity program for a resident, as observations showed the resident spent long periods in the TV Lounge without engaging in meaningful activities. The resident's care plan required one-to-one visits three times a week, which were not consistently provided. The Activity Director confirmed the visits were not conducted as scheduled.
A resident experienced a decline in range of motion in both knees due to the facility's failure to provide necessary care. Initially, the resident had normal range of motion, but by July, contractures were observed. Staff interviews revealed that staffing shortages, particularly among aides, prevented them from completing assignments and providing essential care, such as range of motion exercises. The facility had previously discontinued a restorative program due to these staffing issues.
A facility failed to provide adequate staffing, affecting resident care. A resident with knee contractures did not receive necessary range of motion exercises, as confirmed by medical records and staff interviews. Staff reported consistent understaffing, particularly with aides, leading to incomplete care and the removal of the restorative aide position. Despite requests for agency staff, the facility operated below required staffing levels, impacting the quality of care provided.
A facility failed to accurately document a resident's dental condition during the admission assessment. The resident reported having only four teeth and difficulty chewing, but the clinical admission evaluation incorrectly marked 'own teeth' and left the dental section incomplete. The administrator confirmed the assessment's incompleteness.
Failure to Update Care Plan for Resident Behavioral Issues
Penalty
Summary
The facility failed to ensure that the care plan for Resident #48 was accurate and up to date, as required by regulations. Record review and staff interviews revealed that Resident #48 exhibited behaviors such as wandering into other residents' rooms, drinking from their cups, eating their food, and retrieving ice with bare hands, as well as public urination and using other residents' items. These behaviors were observed and documented by staff, but were not reflected in the resident's care plan. Staff interviews confirmed that the resident required ongoing re-queuing and redirection, and had difficulty adjusting to the facility, yet the care plan did not address these specific behavioral issues.
Failure to Provide Safe Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, as evidenced by multiple instances of blood pressure being taken in the resident's left arm, where an arteriovenous (AV) fistula was located. This practice is against professional standards as it can lead to serious complications such as clots, loss of use of the fistula, and potentially a stroke. The resident's medical records showed several documented instances where blood pressure was taken in the left arm, despite clear orders and care plans indicating that this should not occur. Additionally, the facility did not complete post-dialysis assessments for the resident upon their return from dialysis sessions. The dialysis communication book lacked documentation of these assessments, which are crucial for monitoring the resident's condition and ensuring any complications are promptly addressed. The care plan for the resident included instructions to monitor for signs of infection, edema, and bleeding upon return from dialysis, but these were not consistently followed. Observations revealed that there was no signage in the resident's room or on their person to alert staff about the restricted limb for blood pressure measurements. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the orders and care plan were not adhered to, leading to the deficiency. This oversight placed the resident at immediate risk of serious injury, prompting the state agency to determine the situation as an immediate jeopardy.
Removal Plan
- Resident #9 will be evaluated by the licensed nurse upon return to the facility.
- All dialysis residents have the potential to be affected.
- The Unit Managers/designee conducted an audit for all residents on dialysis with specific B/P orders to be taken and POST dialysis assessment is completed upon return to the facility with any corrective action immediately upon discovery.
- The Order for B/P not to be taken in the Left arm on Resident #9 will be added to the Medication Administration Record in all Capital letters and will be added to the care plan and kardex in capital letters.
- The Director of Nursing(DON)/designee will reeducate all nursing staff with a posttest to validate understanding regarding hemodialysis graft, fistula care, communication, and documentation.
- Verify orders and instructions from hemodialysis facility or hospital, if patient is a new Admission.
- Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications.
- Inspect fistula site for decrease or absence of vein dilation.
- Palpate for distal thrill.
- Auscultate for bruit.
- Palpate skin around graft/fistula for warmth.
- Evaluate skin around vascular access noting redness, swelling, local warmth, exudate, tenderness.
- Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for complications.
- Protect access site from getting wet for several hours after HD or HHD treatment.
- Avoid trauma or treatment procedures in the accessed extremity, such as limiting activity of extremity, blood pressure measurement, venipuncture, injection of any type, use of creams or lotions on the access site.
- Instruct patient to avoid excessive pressure on the extremity or strain and in strengthening exercises to enhance blood flow if permitted by physician/APP and dialysis facility.
- Document location of access site on admission assessment, status of access site in Nurses' notes, status of pulses distal to access area, color and temperature of extremity, presence or absence of pain or numbness, status of bruit and thrill, notification and response of physician/APP and dialysis facility, patient education and family involvement, nursing intervention.
- Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility.
- Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the patient to his/her HD facility visit.
- Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient.
- Upon return of the patient to the Center, a licensed nurse will review the certified dialysis facility communication, evaluate/observe the patient, and complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form.
- Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center.
- Document notification of certified dialysis facility regarding return of form or other communication.
- Maintain the Hemodialysis Communication Record or state required form in the patient's medical record.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work.
- New Licensed nurses will be provided education, including post-test during orientation by the DON/designee.
- Annual in-servicing will be provided to licensed nurses regarding medication administration.
- The DON/designee will complete medication pass competencies quarterly to ensure physician orders are followed including ensuring B/P's are not taken in restricted arm.
- The Unit Managers (UM)/Designee will conduct observations to ensure all licensed nurses are taking B/P and the licensed nurse is completing the dialysis communication sheets POST dialysis daily across all shifts.
- Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Abuse and Neglect Incidents in LTC Facility
Penalty
Summary
The facility failed to provide an environment free from abuse and neglect, as evidenced by two separate incidents involving residents. In the first incident, a Licensed Practical Nurse (LPN) physically abused a resident during an episode of combative behavior. The resident, who had a complex medical history including dementia and chronic kidney disease, became combative during incontinence care. The LPN, in an attempt to administer medication, was spat on by the resident and reacted by striking the resident in the face. This incident was witnessed by multiple staff members and was reported to the facility's administration. In the second incident, a Nurse Aide (NA) neglected a resident by leaving them in a soiled state. The resident was found with vomit on their clothing and dried feces on their legs, and their bed was soiled with urine and feces. The NA responsible for the resident's care admitted to not changing the resident, citing a concern about the resident becoming combative if awakened. This neglect was reported by another NA and confirmed by the LPN assigned to the resident that night. Both incidents were substantiated by the facility, with the staff members involved being terminated. However, the report notes that there was no evidence of education or other actions taken to prevent recurrence of the neglect incident, highlighting a gap in the facility's response to such deficiencies.
Medication Error: Insulin Administered to Non-Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving Resident #65. On April 19, 2024, Resident #65, who was not diabetic and had no insulin order, was mistakenly administered 25 units of insulin. This error occurred after a room change, where the resident was moved from room 401A to 107. The resident reported that the nurse did not verify the identity of the person receiving the insulin shot, leading to the administration of the wrong medication. The progress notes from the incident indicated that the resident's blood sugar was 135 before the insulin was administered, and after the error was discovered, the resident was understandably upset. The on-call doctor was notified, and initial orders were given to monitor the resident's blood sugar every 15 minutes. However, the resident initially refused to have his blood sugar checked, only consenting after speaking with his wife. Subsequent checks showed a blood sugar level of 118. Despite the seriousness of the error, the facility did not provide documentation of any investigation or process implementation to prevent such errors in the future. Interviews conducted during the investigation revealed that the LPN responsible for the error did not verify the resident's identity because they were unaware of the room change. The facility administrator confirmed that a one-to-one education session was conducted with the LPN involved, but this occurred two months after the incident. The LPN was noted to be a part-time or as-needed employee, which may have contributed to the oversight. The lack of immediate corrective action and investigation highlights a systemic issue within the facility's medication administration process.
Failure to Provide Showers and Timely Transfers
Penalty
Summary
The facility failed to provide showers and/or bed baths in accordance with the residents' preferences and/or their care plans. Several residents reported that staff preferred to give bed or sponge baths instead of showers, as it required less effort. This issue was identified for multiple residents, including those who had not received a shower for over thirty days, despite being scheduled for showers multiple times a week. The records showed inconsistencies in the provision of showers and bed baths, with significant gaps between bathing sessions. Resident #42 experienced psychosocial harm due to a delay in being transferred from her chair to her bed. During a night observation, the resident was found crying and repeatedly calling for help. Despite the presence of staff, the resident was not attended to promptly, leading to distress. The LPN on duty acknowledged the resident's agitation due to the delay and the need for assistance with a mechanical lift, which was not immediately available. Other residents, such as Resident #48, #40, and #3, expressed dissatisfaction with the lack of showers, which were important to them as per their Minimum Data Set (MDS) preferences. The facility's records corroborated these claims, showing a pattern of missed showers and infrequent bed baths. Interviews with residents and staff highlighted a systemic issue with the facility's ability to meet the residents' bathing preferences and schedules, contributing to the deficiency identified during the survey.
Infection Control Deficiencies in PPE Use and Waste Disposal
Penalty
Summary
The facility failed to maintain an appropriate infection control program, as evidenced by several observations and staff interviews. Soiled linen was found improperly disposed of, with linen observed on the PPE cart and on the floor in a resident's room. Staff, including a registered nurse and nurse aides, were observed not wearing proper personal protective equipment (PPE) while transferring and providing care to a resident in an Enhanced Barrier Precaution (EBP) room, despite signage indicating the required PPE for specific activities. Additionally, a meal tray that was refused by a resident was placed back onto a cart with clean trays, and uncovered bedpans were found on the floor in a restroom. Further observations revealed soiled gloves discarded on the floor of a hallway, which was confirmed by a licensed practical nurse as an infection control issue. Staff interviews indicated a lack of adherence to proper disposal protocols for soiled gloves and dressings, which should have been discarded in the appropriate receptacles within residents' rooms. These deficiencies in infection control practices had the potential to affect more than an isolated number of residents, given the facility's census of 71.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor residents' preferences for bed baths and showers, affecting five out of seven residents reviewed during the Long-Term Care Survey Process. Resident #60 expressed dissatisfaction with the infrequency of showers, having received only two showers between May and July 2024, despite being scheduled for twice-weekly showers. The Director of Nursing confirmed the lack of showers for Resident #60 since June 19, 2024. Similarly, Resident #63 reported not having a shower since early May 2024, although scheduled for twice-weekly showers, and the Director of Nursing acknowledged this issue. Resident #48 also reported that his requests for showers were not honored, with records showing he received no showers in January, February, and May 2024, and only two showers in June 2024. Despite expressing that choosing between different types of baths was very important to him, his preferences were not met. Resident #40, who indicated that choosing between bath types was somewhat important, received no showers from January to July 2024, with significant gaps between bed/sponge baths. Resident #3, who considered choosing between bath types very important, received only one shower in March and May 2024, and none in July 2024. The records revealed long periods without any form of bathing, such as a 17-day gap in March 2024. The Director of Nursing acknowledged the problem of not honoring residents' bathing preferences and stated that the facility was working on addressing the issue.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information. On July 23, 2024, at 11:04 PM, a Licensed Practical Nurse (LPN) was observed at the nurses' station using a computer. Shortly after, at 11:08 PM, a computer was found unattended on top of the medication cart with resident identifiable information visible on the screen. This situation presented a random opportunity for unauthorized access to sensitive information, potentially affecting more than a minimal number of residents in the facility, which had a census of 71 at the time. During an interview conducted at 11:12 PM, the LPN returned to the medication cart and locked the computer screen, acknowledging awareness that it had been left unlocked. The following day, the Director of Nursing (DON) confirmed in an interview that the computer and medication cart should have been secured to prevent such breaches of confidentiality.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for residents in several rooms, as observed during a facility tour. The tour revealed that multiple resident doors had visible cracks and rough edges with putty applied, indicating inadequate maintenance. Additionally, in one resident's room, the slats of the Packaged Terminal Air Conditioner (PTAC) unit were covered in a moldlike substance. The resident expressed concerns about allergies, which could be related to the mold. The Maintenance Supervisor confirmed the presence of mold and acknowledged the need for cleaning.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and personal care needs. Resident #54's care plan did not include a diagnosis of Dementia, despite it being documented in their medical record. Similarly, Resident #61's care plan lacked interventions for their diagnosed anxiety disorder, even though the resident had been seen for psychological telemedicine visits. Resident #71's care plan was incomplete, missing focus areas such as activities of daily living, suspected infections, and risk for skin breakdown. These omissions were confirmed by the facility's Director of Nursing and Administrator during interviews. Additionally, the facility did not adequately address the personal hygiene preferences of several residents. Resident #51, #65, and #22 reported not receiving showers as per their preferences, with their care plans either lacking specific interventions or not being followed. Resident #9's care plan included an intervention to avoid taking blood pressure in the left arm due to an AV fistula, yet records showed this was not adhered to on multiple occasions. These failures were acknowledged by the facility's administration, indicating a systemic issue in care plan development and implementation.
Unsecured Treatment Cart and Medication in Resident Areas
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible, which had the potential to affect more than a limited number of residents. During an observation, an unlocked and unattended treatment cart was found in the resident TV room, making medication and treatment supplies accessible to residents, unauthorized persons, or visitors. This was confirmed by RN #21, who acknowledged that the treatment cart should not be left unlocked when unattended. Additionally, nystatin powder was found unsecured and unattended at a resident's bedside, allowing access to the medication by residents, unauthorized staff, or visitors. RN #21 confirmed that the medication should not be left out in the room and removed it upon discovery.
Failure to Conduct Yearly Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct yearly performance evaluations for three out of five Nurse Aides reviewed during the survey process. This deficiency was identified through a record review conducted at approximately 2:45 PM on 07/23/24, which revealed missing yearly performance evaluations for Nurse Aides #34, #63, and #61. The facility census at the time was 71. During a staff interview at approximately 3:30 PM on the same day, the Administrator confirmed the absence of these evaluations. The Administrator acknowledged awareness of the missing evaluations and stated that efforts were being made to catch up on them.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to conduct behavior and side effect monitoring for psychotropic medications for one of the five residents reviewed during the Long-Term Care Survey Process. Specifically, Resident #54 was prescribed Lorazepam Oral Tablet 0.5 MG for anxiety, with instructions to monitor for sedation, morning hangover, ataxia, nausea, and to report any side effects to the physician. However, a review of the Medication Administration Record (MAR) revealed that there was no monitoring conducted for the months of December 2023 through May 2024. During an interview, the Director of Nursing confirmed that behavior and side effect monitoring was not being performed.
Incomplete Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to maintain accurate temperature logs for the medication refrigerator, as observed during a survey on July 25, 2024. The survey revealed that the temperature recordings for the medication refrigerator were incomplete from March 2024 through July 2024. Specific dates were identified where the temperature checks were not documented, indicating a lapse in the facility's adherence to its policy of checking refrigerator temperatures twice daily. During the survey, the Administrator confirmed the incompleteness of the temperature logs. The facility's policy, titled 'Medication and Vaccine Refrigerator/Freezer Temperatures,' mandates that refrigerators and freezers used for storing medications and vaccines must operate within an acceptable temperature range and be checked twice daily. The failure to record these temperatures as per the policy could potentially affect more than a limited number of residents, given the facility's census of 71.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to ensure that food items were discarded after their expiration date, which had the potential to affect more than a limited number of residents. During an initial observation in the kitchen, scalloped potatoes were found wrapped in plastic wrap in the walk-in refrigerator with a discard date of 07/11/24, indicating they were out of date. Additionally, a box of onions in the walk-in refrigerator contained eight onions, four of which were covered in what appeared to be mold. During an interview, the Dietary Manager in Training (DMT) acknowledged that the potatoes were out of date and stated that they would dispose of the potatoes and onions. This deficiency was identified during a survey with a facility census of 71 residents.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that the resident call system was functioning as designed, which had the potential to affect more than a limited number of residents. During an observation tour of the 200 and 300 halls, it was found that the call light system was turned off at the end of the halls, and the volume was too low to be heard throughout the unit. The Maintenance Assistant verified that the system was turned off and stated that the staff had turned it off. The Maintenance Director confirmed that the call system was both visual and audible and noted that all the call systems in the building had been turned down since he started working there.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State ombudsman of a discharge for a resident, identified as Resident #71. This deficiency was identified during a record review conducted on 07/23/24, which revealed that the resident had been discharged to another facility on 05/09/24. However, there was no evidence that the required notification of discharge was sent to the State ombudsman. During an interview on the same day, the Administrator confirmed the absence of the notification to the Ombudsman regarding the discharge.
Inaccurate MDS Discharge Destinations for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments regarding the discharge destinations for two residents. For Resident #71, the record review revealed that the resident was discharged to another long-term care facility, but the MDS inaccurately listed the discharge destination as home. This discrepancy was confirmed by the Administrator. Similarly, for Resident #72, the record review showed that the resident was discharged to home, yet the MDS incorrectly recorded the discharge destination as a short-term general hospital. The Administrator also confirmed this error. These inaccuracies were identified during a record review and staff interview process.
Failure to Revise Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident when the status of her pressure ulcer changed. A record review revealed an order for the resident's right heel, which was initially documented as a Stage IV pressure ulcer requiring specific wound care. However, the care plan inaccurately listed the ulcer as a Stage 2 pressure ulcer. A subsequent skin and wound evaluation indicated that the pressure ulcer was unstageable, yet the care plan was not updated to reflect this change. During an interview, the Director of Nursing acknowledged the issue, stating that there were ongoing problems with care plan revisions.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an activity program that met the needs and interests of its residents, specifically for one resident identified in the report. Observations revealed that the resident spent extended periods sitting in the Television Lounge without engaging in meaningful activities. The resident's care plan emphasized the importance of engaging in daily routines that were meaningful and included scheduled one-to-one visits three times a week, which were not consistently provided. A review of the resident's activity participation records for several months showed a lack of consistent one-to-one visits and no participation in group activities. The Activity Director confirmed that the scheduled one-to-one visits were not being conducted as planned. This deficiency highlights the facility's failure to adhere to the resident's care plan and provide the necessary engagement opportunities to meet the resident's preferences and needs.
Failure to Prevent Reduction in Range of Motion Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary services and treatment to a resident to prevent a reduction in range of motion. Resident #64, who initially had normal range of motion in the lower extremities as per evaluations and records from March and April 2024, was observed to have contractures in both knees by July 2024. The resident reported not receiving assistance with range of motion exercises during care, and the medical records indicated a decline in range of motion by June 2024. Interviews with staff, including nurse aides and registered nurses, revealed that the facility was experiencing staffing shortages, particularly among aides. This shortage resulted in insufficient time to complete assignments and provide necessary care, such as range of motion exercises. The facility previously had a restorative program to address such needs, but it was discontinued due to staffing issues, contributing to the deficiency in care for Resident #64.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by the experiences of a resident and multiple staff members. A resident, identified as having contractures in both knees, reported not receiving assistance with range of motion exercises, which were previously within normal limits according to medical records. The resident's condition deteriorated without the necessary care, highlighting the facility's inability to maintain adequate staffing levels to ensure proper resident care. Interviews with nurse aides and registered nurses confirmed that the facility was consistently understaffed, particularly with aides, leading to incomplete care assignments and the removal of the restorative aide position. Staff interviews revealed that the facility typically operated with fewer aides than required, particularly during the day shift, and that weekends were often worse. Aides reported being asked to work extra hours frequently due to staffing shortages, which affected their ability to provide comprehensive care, such as assisting with range of motion exercises and ensuring residents received showers. Despite repeated requests for agency staff to alleviate the situation, these requests were not fulfilled, and management reportedly deflected responsibility onto the staff. The administrator acknowledged the need for more aides but confirmed that the facility often operated below the necessary staffing levels.
Incomplete Dental Assessment Documentation
Penalty
Summary
The facility failed to accurately document the dental condition of a resident during the admission assessment. During an interview, the resident stated that they only have four teeth and have difficulty chewing food. However, a review of the resident's clinical admission evaluation revealed that the section regarding dental condition was incomplete, with the box indicating 'own teeth' marked incorrectly. The administrator confirmed the incompleteness of the dental assessment upon review.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
