SUNDALE NURSING HOME
For profit - Limited Liability company
100 Beds
Independent
Data: November 2025
Trust Grade
68/100
#41 of 122 in WV
Photo by Igor Lima
Photo by Igor Lima
Photo by Igor Lima
1 / 10 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sundale Nursing Home in Morgantown, West Virginia, has a Trust Grade of C+, indicating it is slightly above average compared to other facilities. It ranks #41 of 122 statewide, placing it in the top half, and is the top facility out of four in Monongalia County. However, the facility is experiencing a troubling trend, as issues have increased from 4 to 9 over the past year. Staffing is rated as good, with a 4/5 star rating and a turnover rate of 41%, which is lower than the state average. On the downside, the facility has been fined $5,000, and there are concerning incidents, such as failing to document grievances and not monitoring residents' significant weight changes, which could pose health risks. Despite these weaknesses, the nursing home has a solid RN coverage and good overall ratings, but families should weigh both the strengths and weaknesses when considering this facility.
- Trust Score
- C+
- In West Virginia
- #41/122
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 41% turnover. Near West Virginia's 48% average. Typical for the industry.
- Penalties ✓ Good
- $5,000 in fines. Lower than most West Virginia facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 44 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
68/100
Top 33%
No red flags
4 → 9 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 9 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below West Virginia average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 41%
Near West Virginia avg (46%)
Typical for the industry
Federal Fines: $5,000
Below median ($33,413)
Minor penalties assessed
The Ugly 31 deficiencies on record
Jan 2025
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence that the long-term care Ombudsman wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence that the long-term care Ombudsman was sent a copy of the written Notice of Transfer for acute hospital transfers. This was true for two (2) out of two (2) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #28 and #4. Facility census: 85.
Findings included:
a) Resident #28
A record review, completed on 01/14/25 at 9:26 AM, revealed that Resident #28 had been transferred to the hospital on [DATE]. Although the Notice of Transfer/Discharge was given to the resident at the time of transfer, there was no evidence that the facility had sent a copy of the notice to the long-term care Ombudsman.
During an interview on 01/14/25 at 11:19 AM, the Director of Social Services stated that she had not yet sent a notification to the long-term care Ombudsman. She stated, We do a log, I am way behind on my log. We try to do it no less than yearly.
b) Resident 4
Medical Record review on 01/14/25 revealed resident #4 was discharged to the hospital on [DATE] and 11/30/24.
Subsequent review of Resident #4's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Ombudsman.
On 01/14/25 at 11:26 AM during an interview the Social Worker verified, there was no evidence that the Notice of Transfer or Discharge was sent to the Ombudsmen for the discharges on 09/29/24 or 11/30/24. She stated that she was behind on the Transfer or Discharge log.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, the facility failed to identify Major Depressive disorder on Preadmission Screening and Resident Review (PASARR). This was found true for one (1) of three ...
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Based on record review and staff interviews, the facility failed to identify Major Depressive disorder on Preadmission Screening and Resident Review (PASARR). This was found true for one (1) of three (3) residents reviewed during the long-term care survey process. Resident identifier: Resident #53. Facility Census: 85
Findings included:
a) Resident #53
A record review conducted on 01/07/25, at approximately 11:45 AM for Resident #53 revealed that the PASARR completed on 03/18/24 did not include any diagnoses of Mental Disorder (MD) or Intellectual Disability (ID). Record reviews also indicated that Resident #53 had been diagnosed with Major Depressive Disorder (MDD) on 11/26/24. Further record review revealed no updated PASARR that captured the MDD diagnosis.
During an interview, with the Director of Nursing (DON), on 01/09/24 at approximately 10:55 AM, she confirmed that the PASARR did not reflect the new diagnosis of Major Depressive Disorder. She further stated that she would notify Social Services of the deficiency.
On 01/13/24 at approximately 12:12 PM, during an interview with the Director of Social Services (DSS) #15, she confirmed that the PASARR and Care Plan had not been updated to reflect the new diagnosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure that the Resident had a person-centered, comprehensive care plan, developed and implemented to meet his / her preferences and ...
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Based on record review and staff interview, the facility failed to ensure that the Resident had a person-centered, comprehensive care plan, developed and implemented to meet his / her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of nine (9) residents' care plans reviewed during the Long-Term Care Survey Process (LTCSP). This failure to ensure that the comprehensive care plan was developed to ensure the residents' highest practicable well-being placed the resident at risk of not receiving services that would meet their desires or needs. Resident Identifier: Resident #53. Facility Census: 85.
Findings included:
a) Resident #53
During a review of Resident #53's current diagnoses performed on 01/07/25 at approximately 11:45 AM, revealed that the resident had been diagnosed with Major Depressive Disorder (MDD) on 11/26/24. Continued review revealed the resident's current care plan did reflect specific interventions to address the symptoms and management of MDD. The care plan, however, did address interventions for the management of the symptoms of the medications prescribed for MDD.
The review of Resident #53's Care Plan on 01/07/25 revealed the following:
PSYCHOTROPIC - (Resident name) is at risk for side effects/complications from psychotropic medication use. Ordered trazodone for MDD, Seroquel for psychosis, and Depakote for psychosis.
Has tearfulness, difficulty sleeping, hallucinations, paranoia, delusions, agitation, etc. She is a hospice patient with terminal dx (diagnosis) of HTN (high blood pressure), Heart Disease with HF (heart failure). Date Initiated: 01/17/2024 Revision on: 11/26/2024
On 01/09/25 at 2:06 PM, the Director of Nursing (DON) confirmed the care plan addressed the side effects and complications of the psychotropic medications prescribed for MDD, but did not specifically address the needs of a resident with MDD. She stated that Social Services would know more about the diagnosis.
During an interview with the Director of Social Services (DSS) #15, on 01/13/25 at approximately 12:12 PM, she confirmed that the Care Plan had not been updated to reflect and address the diagnosis of MDD.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review, and staff interview, the facility failed to follow physician orders related to administration of pain medication. This was true for one (1) of three (3) residents reviewed for ...
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Based on record review, and staff interview, the facility failed to follow physician orders related to administration of pain medication. This was true for one (1) of three (3) residents reviewed for pain during the annual long-term care survey process. Resident identifier: #2. Facility census: 85.
Findings included:
a) Resident #2
A record review was completed on 01/08/25 at 7:00 PM. The record review demonstrated that Resident #2 had the following physician order: Hydrocodone-Acetaminaphen oral tablet 5-325 MG. Give 1 tablet by mouth every 6 hours as needed for pain related to pain, for severe pain (7-10).
Review of the December 2024 and January 2025 Medication Administration Records (MARs) revealed the following dates the medication was administered outside the physician's parameters for severe pain.
December 2024
-12/10/24 Pain Level of 6
-12/11/24 Pain Level of 3
-12/25/24 Pain Level of 3
January 2025
-12/06/26 Pain Level of 3
During an interview on 01/09/25 at 8:56 AM, the Director of Nursing (DON) acknowledged the medication was administered outside of the parameters set in the physician's order for severe pain ranked 7 - 10. She recognized it was the same nurse who had made the error and stated that the nurse would be re-educated and disciplined.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to complete a comprehensive social services assessment in its entirety for Resident #35. This was a random opportunity for discovery. Re...
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Based on record review and staff interview, the facility failed to complete a comprehensive social services assessment in its entirety for Resident #35. This was a random opportunity for discovery. Resident identifier: #35. Facility census: 85.
Findings included:
a) Resident #35
During a record review, on 01/13/25 at 11:29 AM, it was identified that the following questions were left unanswered on the comprehensive social services assessment, dated 06/25/24.
Question 12: Date capacity determined by MD
Question 13: Competency (Guardian, Conservator, or Both)
Question 14: Current Pain Medications
Further record review revealed:
-The most recent physician determination of capacity was on 05/22/24
-Resident #35 had both a court appointed legal guardian and a conservator effective 01/28/13
-Resident #35 was ordered Tramadol pain medication, an order that began on 07/20/23.
During an interview, on 01/13/25 at 2:15 PM, the Director of Social Services acknowledged the questions were left blank and were unanswered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to document voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and maintain ev...
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Based on interview and record review, the facility failed to document voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and maintain evidence of the result of all grievances for no less than 3 years from the date the grievance decision was issued. This has the potential to affect, more than a limited number of Residents. Facility census: 85.
Findings Included:
Record review of the facility's policy titled, Resident and Family Grievances, showed:
--The grievance official is responsible for overseeing the grievance process: receiving and tracking grievances through their conclusion.
--Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. A grievance log will be maintained for each calendar year.
a) Grievance Process
A record review on 01/08/25 of grievances revealed no grievance forms or logs were filled out for the last two years.
During an interview with the Social Services Director (SSD) on 01/08/25 at 2:22 PM SSD states that the facility has not had any grievances in the last two years, and they do not keep a list of concerns. She continued to say that the facility lets each department take care of any complaint made at that department.
During an interview with the Administrator on 01/08/25 at approximately 2:50 PM, she stated that the residents or representative has to say they want to file a formal grievance before they would write the concern / grievance on a formal grievance form. She stated that she feels that care, treatment, medication issues, lost personal items or perceived rudeness is just an informal complaint, and the facility does not log them or consider them a grievance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on observation, record review, and staff interview, the facility failed to ensure accurate weights were obtained for three (3) out of three (3) residents sampled for weight loss. Failure to moni...
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Based on observation, record review, and staff interview, the facility failed to ensure accurate weights were obtained for three (3) out of three (3) residents sampled for weight loss. Failure to monitor and investigate significant changes in resident's weight status places the residents at risk for an incorrect assessment or diagnosis of impaired nutrition or hydration status. Further, this failed practice potentially prevented the interdisciplinary team from accurately developing and implementing interventions to stabilize or improve the resident's nutritional status before complications arose. Resident Identifiers: Residents #24, #53 and #78. Facility Census:85.
The findings included:
a) Resident #24
During a review of Resident #24's weights on 01/09/25 at approximately 9:18 AM, the following values were revealed:
10/1/2024 21:28
175.9 Lbs
11/1/2024 23:28
175.9 Lbs
12/1/2024 20:35
177.2 Lbs
1/8/2025 19:29
160.4 Lbs
Based on these records, the resident experienced a weight loss of 16.8 pounds, (9.4% of body weight), over a period of 37 days, between 12/01/24 and 01/08/25.
A review of Resident #24's care plan revealed the following:
PROBLEM:
[Resident] has the potential for decreased fluid status, AEB constipation, hx of UTI, and intake less than 75%. Limited fluid preferences. Family provides beverage of choice (Mountain Dew)
Date initiated: 11/13/2018 Revision: 09/19/2024
APPROACHES/TASKS:
Encourage the resident to drink fluids of choice with and between meals
Date initiated: 11/13/2018
Revision: 09/10/2020
Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output. Concentrated urine. Strong odor. Tenting skin. Cracked lips. Furrowed tongue. New onset confusion. Dizziness. Fever. Thirst. Recent/sudden weight loss. Dry/sunken eyes.
Date initiated: 03/18/2021
Offer fluids when giving medication
Date initiated: 11/13/2018
Provide supplements as ordered by MD
Date initiated: 04/09/2024
Record review on 01/13/25 at 11:35 AM revealed no documentation that the nurse was aware of the weight loss.
b) Resident #53
During the record review of Resident #53's weights on 01/07/25 at approximately 3:15 PM, the following values were seen:
3/1/2024 06:33
208.1 Lbs
3/12/2024 18:23
202.6 Lbs
4/1/2024 06:12
217.3 Lbs
4/2/2024 15:07
213.5 Lbs
This record shows that Resident #53 experienced a weight loss of 5.5 pounds in 11 days, between 03/01/24 and 03/12/24.
In addition, the resident also experienced a significant weight gain of 14.7 pounds (6.76% of body weight), over a period of 19 days, between 03/12/24 and 04/01/24
Ongoing record review revealed a nutritional assessment and dietitian note on 03/29/24 that stated the following:
Resident's significant change nutritional assessment completed. NKFA. Weight reflects significant weight gain over past one month. Resident was admitted to hospice. Resident has her own teeth was some missing. She eats all meals in her room per her request. Diuretic therapy; weight fluctuations may occur with diuretic therapy.
The record review showed that the resident was prescribed Spironolactone once daily. However, there was no documentation that the weight gain was investigated, or that the physician was notified.
Further, clinical evidence has shown that dehydration and weight loss, not weight gain, are associated with diuretic therapy.
c) Resident #78
Record review on 01/07/25 at approximately 1:45 PM revealed the following:
12/23/2024 06:29
147.8 Lbs
12/24/2024 06:13
147.4 Lbs
12/25/2024 11:49
161.0 Lbs
12/26/2024 06:03
161.0 Lbs
This weight record revealed that Resident #78 gained 13.6 pounds (9.22% of her body weight), in one (1) day, between 12/24/24 and 12/25/24.
Record review also reveals that the resident lost 11.8 pounds (7.39% of her body weight) in one (1) day between 12/22/24 and 12/23/24.
Further record review revealed a dietitian's note on 01/02/25 which stated the following:
[Resident's] plan of care reviewed and updated. CW is 161.7 lbs. with a BMI of 26.9. CW reflects significant weight loss of 6.9% over past 1 month, 8.0% over past 3 months and weight gain of 10.2% over past 6 months. Will alert MD of significant weight changes via weight change stamp. Diet is Regular with PO intakes over past week as noted: 2 meals @ 0-25%, 9 meals @ 26-50%, 5 meals @ 51-75%, 3 meals @ 76-100%. She eats breakfast and supper in her room and in fine dining for lunch and supper. Dietary is providing 3780 cc which exceeds her estimated fluid needs of 2059 cc, calculated using his adjusted weight of 151 lbs. @ 30 cc/kg. Dx. of Depression may affect PO intakes. Dx. of Edema. Will continue with current goals and approaches, review plan of care quarterly.
On 01/13/25 at approximately 1:54 PM, Registered Nurse (RN) #80 and Nursing Assistant (NA) #24 were observed weighing Resident #78 with the aid of a Hoyer lift.
The resident was seated in a wheelchair with a blue sling underneath her. RN #80 first zeroed the scale on the Hoyer lift, and then lowered it so that NA #24 could attach the sling to the lift bar. Once the sling was securely attached, the resident was hoisted up and moved away from the wheelchair, ensuring that her extremities were protected during the process.
Once hoisted, the resident was weighed, and her weight was recorded as 164.6 pounds. She was then carefully transferred and lowered into her bed. The sling was removed, and the resident was made comfortable.
When questioned about the resident's weight, RN #80 explained that she would deduct the weight of the blue sling from the recorded weight to determine the resident's actual weight. Upon being asked about the sling's weight, RN #80 stated it was 2.2 pounds. She mentioned that she had found this information in the manufacturer's manual.
The Centers for Medicare Services (CMS) interpretative guidelines suggest the following parameters for evaluating the significance of unplanned and undesired weight loss:
Interval
Significant Loss
Severe Loss
1 month
5%
Greater than 5%
3 months
7.5%
Greater than 7.5%
6 months
10%
Greater than 10%
On 01/08/25 at 1:15 PM, the Quality Assurance Trainer (QA Trainer) #104 presented the facility's protocols for staff training, including weight monitoring. A review of the training protocol revealed that if weights varied by five (5) pounds from a previous weight, the nurse was to be notified.
During an interview with QA Trainer #104 on 01/14/25 at 10:55 AM, he stated that the staff were required to notify the nurse on duty of a weight change of five (5) pounds or over.
The Director of Nursing (DON) was interviewed on 01/13/25 at 10:45 AM and notified of the significant weight changes. DON confirmed that the significant and severe changes in weight were due to the staff's inaccurate weighing of residents. She further stated that the residents should have been re-weighed when the discrepancies were noted.
The QA Trainer #104 stated during the interview on 01/14/25 at 10:55 AM that all the scales were checked monthly to ensure all facility scales were calibrated correctly. In addition, he stated that he did not think the problem of having inconsistent weights was with the scales but with the weighing techniques of the staff. He further stated that based on the survey findings, he was creating a training program for the staff to ensure that they weighed residents accurately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to notify the physician of a resident's significant change in weight, and failed to ensure that the physician conducted a medical evaluation o...
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Based on record review and interview, the facility failed to notify the physician of a resident's significant change in weight, and failed to ensure that the physician conducted a medical evaluation of a resident with a sudden significant change in weight. As a result, the residents were not evaluated to determine the cause for the sudden change in body weight. This placed the resident at risk for serious harm or death. Resident Identifiers: Resident #24, #53, and #78. Facility Census: 85.
Findings Included:
a) Resident #24
During a review of Resident #24's weights on 01/09/25 at approximately 9:18 AM, the following values were revealed:
-10/1/2024 21:28
175.9 Lbs
-11/1/2024 23:28
175.9 Lbs
-12/1/2024 20:35
177.2 Lbs
-01/8/2025 19:29
160.4 Lbs
Based on these records, the resident experienced a weight loss of 16.8 pounds, (9.4% of body weight), over a period of 37 days, between 12/01/24 and 01/08/25.
A review of Resident #24's care plan revealed the following:
PROBLEM:
[Resident] has the potential for decreased fluid status, AEB constipation, hx of UTI, and intake less than 75%. Limited fluid preferences. Family provides beverage of choice (Mountain Dew)
Date initiated: 11/13/2018 Revision: 09/19/2024
APPROACHES/TASKS:
-Encourage the resident to drink fluids of choice with and between meals
Date initiated: 11/13/2018
Revision: 09/10/2020
-Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output. Concentrated urine. Strong odor. Tenting skin. Cracked lips. Furrowed tongue. New onset confusion. Dizziness. Fever. Thirst. Recent/sudden weight loss. Dry/sunken eyes.
Date initiated: 03/18/2021
Offer fluids when giving medication
Date initiated: 11/13/2018
Provide supplements as ordered by MD
Date initiated: 04/09/2024
Record review on 01/13/25 at 11:35 AM revealed no documentation that the nurse was aware of the weight loss, or that the physician had been notified.
b) Resident #53
During the record review of Resident #53's weights on 01/07/25 at approximately 3:15 PM, the following values were seen:
-03/01/2024 06:33
208.1 Lbs
-3/12/2024 18:23
202.6 Lbs
-04/01/2024 06:12
217.3 Lbs
-04/02/2024 15:07
213.5 Lbs
This record shows that Resident #53 experienced a weight loss of 5.5 pounds in 11 days, between 03/01/24 and 03/12/24.
In addition, the resident also experienced a significant weight gain of 14.7 pounds (6.76% of body weight), over a period of 19 days, between 03/12/24 and 04/01/24
Ongoing record review revealed a nutritional assessment and dietitian note on 03/29/24 that stated the following:
Resident's significant change nutritional assessment completed. NKFA (No known food allergies). Weight reflects significant weight gain over past one month. Resident was admitted to hospice. Resident has her own teeth was some missing. She eats all meals in her room per her request. Diuretic therapy; weight fluctuations may occur with diuretic therapy.
The record review showed that the resident was prescribed Spironolactone once daily. However, clinical evidence has shown that dehydration and weight loss, not weight gain, are associated with diuretic therapy.
Record review revealed no documentation that the weight gain was investigated, or that the physician was notified.
c) Resident #78
Record review on 01/07/25 at approximately 1:45 PM revealed the following:
12/23/2024 06:29
147.8 Lbs
12/24/2024 06:13
147.4 Lbs
12/25/2024 11:49
161.0 Lbs
12/26/2024 06:03
161.0 Lbs
This weight record revealed that Resident #78 gained 13.6 pounds (9.22% of her body weight), in one (1) day, between 12/24/24 and 12/25/24.
Record review also reveals that the resident lost 11.8 pounds (7.39% of her body weight) in one (1) day between 12/22/24 and 12/23/24.
Further record review revealed a dietitian's note on 01/02/25 which stated the following:
[Resident's] plan of care reviewed and updated. CW is 161.7 lbs. with a BMI of 26.9. CW reflects significant weight loss of 6.9% over past 1 month, 8.0% over past 3 months and weight gain of 10.2% over past 6 months. Will alert MD of significant weight changes via weight change stamp. Diet is Regular with PO intakes over past week as noted: 2 meals @ 0-25%, 9 meals @ 26-50%, 5 meals @ 51-75%, 3 meals @ 76-100%. She eats breakfast and supper in her room and in fine dining for lunch and supper. Dietary is providing 3780 cc which exceeds her estimated fluid needs of 2059 cc, calculated using his adjusted weight of 151 lbs. @ 30 cc/kg. Dx. of Depression may affect PO intakes. Dx. of Edema. Will continue with current goals and approaches, review plan of care quarterly.
Once again, record review revealed no documentation that the physician was notified of the sudden changes in body weight.
The Centers for Medicare Services (CMS) interpretative guidelines suggest the following parameters for evaluating the significance of unplanned and undesired weight loss:
Interval
Significant Loss
Severe Loss
1 month
5%
Greater than 5%
3 months
7.5%
Greater than 7.5%
6 months
10%
Greater than 10%
On 01/08/25 at 1:15 PM, the Quality Assurance Trainer (QA Trainer) #104 presented the facility's protocols for staff training, including weight monitoring. A review of the training protocol revealed that if weights varied by five (5) pounds from a previous weight, the nurse was to be notified.
During an interview with QA Trainer #104 on 01/14/25, at 10:55 AM, he stated that staff were required to notify the on-duty nurse of any weight change of five pounds or more.
The Director of Nursing (DON) was interviewed on 01/13/25 at 10:45 AM and notified of the significant weight changes. DON confirmed that the significant and severe changes in weight were due to the staff's inaccurate weighing of residents. She further stated that the residents should have been re-weighed when the discrepancies were noted.
The QA Trainer #104 stated during the interview on 01/14/25 at 10:55 AM that all the scales were checked monthly to ensure all facility scales were calibrated correctly. In addition, he stated that he did not think the problem of having inconsistent weights was with the scales but with the weighing techniques of the staff. He further stated that based on the survey findings, he was creating a training program for the staff to ensure that they weighed residents accurately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interviews, the facility failed to store food in a safe sanitary manner in regard to storing medical ice packs in the freezer in the residents pantry. This has the poten...
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Based on observation and staff interviews, the facility failed to store food in a safe sanitary manner in regard to storing medical ice packs in the freezer in the residents pantry. This has the potential to affect a limited number of residents. Facility census: 85.
Findings Included:
a) Two South Resident Pantry
During the tour on 01/08/25 at 9:20 AM to the Resident pantry, two (2) medical Ice packs were observed stored in resident freezer.
An interview, on 01/08/25 at 9:20 AM, with the Dietary Manager confirmed the medical ice packs should not be stored with resident food.
Jan 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to develop and/or implement a care plan regarding fall prevention interventions for Resident #38 and #9. Resident Identifi...
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Based on observation, record review, and staff interview, the facility failed to develop and/or implement a care plan regarding fall prevention interventions for Resident #38 and #9. Resident Identifiers: #38 and #9. Facility Census: 85.
Findings Included:
a) Resident #38
On 01/03/24 at 10:07 AM, a record review was completed for Resident #38. The review found the fall prevention interventions on the care plan had not been implemented. An observation of Resident #38's wheelchair found no anti-roll backs were in place. Nurse Aide (NA) #104 confirmed the anti-roll backs were not in place. The resident was found to have multiple falls throughout the stay at the facility.
On 01/03/24 at 10:15 AM, the record review found an additional fall prevention intervention of check q (every) 30 minute checks to ensure toileting and ADL (activities of daily living) needs were met. However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no 30 minute documentation found to verify the checks were completed.
On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every 30 minutes .they would be charting all day.
No further information was obtained during the survey process.
b) Resident #9
On 01/03/24 at 10:20 AM, a record review was completed for Resident #9. The review found a fall prevention intervention on the care plan had not been implemented. The fall prevention intervention was check q hour for toileting and ADL needs. The resident was found to have multiple falls throughout the stay at the facility.
However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no hourly documentation found to verify the checks were completed.
On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every hour .they would be charting all day.
No further information was obtained during the survey process.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to revise a careplan related to a significant weight loss and to include supplements. This was a random opportunity for discovery. Reside...
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Based on record review and staff interview the facility failed to revise a careplan related to a significant weight loss and to include supplements. This was a random opportunity for discovery. Resident identifier # 81. Facility census 85.
Findings included:
a) Resident #81
During a record review on 01/02/24 at 1:00 PM of Resident #81's orders, it revealed Resident #81 was ordered Ensure Plus one time a day for significant weight loss on 12/19/23
During a record review on 01/02/24 at 1:15 PM of Resident #81's dietary care plan it read Resident #81 was a significant weight gain at 3 and 6 months, revised on 10/17/23. There is no mention of supplements.
During an interview on 01/03/24 at 9:30 AM wit the Director of Nursing (DON), she stated, I don't feel its necessary to add the supplement to the care plan if they are on a regular diet, our dietary manager updates the dietary careplan's.
During and interview on 01/03/24 at 9:45 AM the Dietary Manager stated, The supplement for resident #81 is not in the care plan. I am the one that adds those to careplan and I missed that one.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to follow the physician's orders regarding fall prevention interventions for Resident #38 and #9. Resident Identifiers: #3...
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Based on observation, record review, and staff interview, the facility failed to follow the physician's orders regarding fall prevention interventions for Resident #38 and #9. Resident Identifiers: #38 and #9. Facility Census: 85.
Findings Included:
a) Resident #38
On 01/03/24 at 10:07 AM, a record review was completed for Resident #38. The review found the physician's orders for the fall prevention interventions were not being followed . An observation of Resident #38's wheelchair found no anti-roll backs were in place. Nurse Aide (NA) #104 confirmed the anti-roll backs were not in place. The resident was found to have multiple falls throughout the stay at the facility.
On 01/03/24 at 10:15 AM, the record review found an additional physician's order for a fall prevention intervention of check q (every) 30 minute checks to ensure toileting and ADL (activities of daily living) needs were met. However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no 30 minute documentation found to verify the checks were completed.
On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every 30 minutes .they would be charting all day.
No further information was obtained during the survey process.
b) Resident #9
On 01/03/24 at 10:20 AM, a record review was completed for Resident #9. The review found the physician's order for a fall prevention intervention was not being followed. The fall prevention intervention was check q hour for toileting and ADL needs. The resident was found to have multiple falls throughout the stay at the facility.
However, the documentation only found shift (every eight (8) hours) notes which were identified with a check mark under the tasks tab. There was no hourly documentation found to verify the checks were completed.
On 01/03/24 at 10:45 AM, an interview was held with the Director of Nursing (DON). The DON stated, the staff documents every shift .if they charted every hour .they would be charting all day.
No further information was obtained during the survey process.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility policy the facility failed to serve house snacks in a sanitary manor, by serving snacks off of a cart which included dirty dishes. This was a random...
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Based on observation, staff interview, and facility policy the facility failed to serve house snacks in a sanitary manor, by serving snacks off of a cart which included dirty dishes. This was a random opportunity for discovery. This failed practice was true for two (2) of two (2) residents. Resident identifiers #9 and #16. Facility census 85.
Findings included:
a) Resident #9
During an observation on 01/03/24 at 10:00 AM Dietary Aide Employee #52 was putting house snacks at the nurses station from cart that was covered in dirty dishes which she had collected on her way down the hall.
During an interview on 01/03/24 at 10:02 AM with Dietary Aide employee #52, she stated, This is how I do it.
During an interview on 01/03/24 at 10:16 AM with Dietary Manager she stated, No this is not how it is done. She knows better than to do it that way.
During a review on 01/02/24 at 10:30 AM of the facilities policy titled, (facilities name) Nursing Home Nourishment Policy, it reads {When Dietary Personnel delivering nourishments, all food items must be kept clean and free from cross contamination of soiled dishes. No dirty dishes should be placed on cart used to deliver nourishments.}
Feb 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident. This deficient practice was found for one (1) of 20 resident...
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Based on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident. This deficient practice was found for one (1) of 20 resident MDS assessments reviewed during the Long Term Care Survey Process. Resident identifier: #60.
Facility census: 84.
Findings included:
a) Resident #60
During a medical record review on 02/21/23 for Resident #60 revealed the significant change MDS completed on 01/12/23 was not coded correctly for a fall on 01/01/23.
In an interview with the MDS Coordinator #25 on 02/22/23 at 9:25 AM, verified the fall on 01/01/23 was not coded correctly in Section J for falls.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to develop a comprehensive person- centered care plan for Resident #27. This was discovered for one (1) of three (3) residents reviewe...
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Based on record review and staff interview, the facility failed to develop a comprehensive person- centered care plan for Resident #27. This was discovered for one (1) of three (3) residents reviewed for the care area of nutrition during the Long Term Care Survey Process. Resident identifier: #27.
Facility census: 84.
Findings included:
a) Resident #27
During a medical record review for Resident #27 on 02/22/23, revealed the comprehensive care plan for decreased nutritional status was not developed to include the physician's order for double breakfast portions since 07/24/17.
In an interview with the Dietary Manager on 02/22/23 at 11:35 AM, verified the care plan did not include the double portions for breakfast.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The deficient practice was true ...
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Based on record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The deficient practice was true for one (1) of four (4) residents reviewed for the care area of falls during the Long Term Care Survey Process. Resident identifier: #60. Facility census: 84.
Findings included:
a) Resident #60
A medical record review on 02/22/23 for Resident #60, revealed there were orders for resident to be wearing hipsters at all times and have a non-skid pad to the wheelchair at all times for fall precautions.
During an observation with LPN #38 on 02/22/23 at 10:38 AM, verified that Resident #60 was not wearing any hipsters and there was no non-skid cushion in the wheelchair.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A multi-use tuberculin puri...
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Based on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A multi-use tuberculin purified protein derivative (PPD) vial was not dated when opened to determine when the vial should be discarded. This was a random opportunity for discovery that had the potential to affect residents receiving tuberculin PPD injections. Facility census: 84.
Findings included:
a) First-floor Medication Room
On 02/21/23 at 1:15 PM, inspection of the first-floor medication room was made. Registered Nurse (RN) #120 was in attendance.
In the medication room refrigerator, an opened multi-dose vial of tuberculin Purified Protein Derivative (PPD) was noted to not have been dated when first accessed. Tuberculin purified protein derivative is given by injection to aid in the diagnosis of tuberculosis. A vial of tuberculin PPD which has been entered and in use for 30 days should be discarded, according to the manufacturer's package insert available on the Food and Drug Administration (FDA) website. RN #84 confirmed the vial had not been dated when opened.
No further information was provided through the completion of the survey.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on observation and record review, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A medication cart and a treatm...
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Based on observation and record review, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A medication cart and a treatment cart were unlocked with no one in attendance. These were random opportunities for discovery that had the potential to affect residents who were able to access the carts. Resident identifiers: #34, #73, #60, #21, #54, #78, #38, #135, #8, #81, #72, #76, #9. Facility census: 84.
Findings included:
a) Medication cart
On 02/21/23 at 8:28 AM, the medication cart in the 100 hallway was noted to be unlocked. No staff member was present. Licensed Practical Nurse (LPN) #13, who was administering medications, came out of a resident room and verified the medication cart was unlocked.
According to information provided by the facility, the following residents were known to wander around the facility: #34, #73, #60, #21, #54, #78, #38, #135, #8, #81, #72, #76, and #9.
b) Treatment Cart
On 02/21/23 at 10:28 AM, the treatment cart was observed unlocked and unattended by staff.
On 02/21/23 at 10:30 AM, Registered Nurse (RN) #126 confirmed the treatment cart was left unlocked and unattended. RN #126 stated, I'm sorry.
On 02/21/22 at approximately 12:30 PM, the Director of Nursing (DON) was notified and confirmed the treatment cart should be locked at all times when left unattended.
No further information was obtained during the long-term survey process.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour ...
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Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour it was discovered dry food bins had not been dated when filled. This had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 84.
Findings included:
a) Kitchen tour
During the kitchen tour on 02/20/23 at 11:43 AM, it was discovered the flour, sugar and rice bins had not been dated when they were filled last.
In an interview with the Dietary Manager (DM) on 02/20/23 at 11:50 AM, verified the flour, sugar and rice bins had not been dated when refilled.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on medical record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmissio...
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Based on medical record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Resident hand hygiene was not performed before the noon meal. This was a random opportunity for discovery. Resident identifiers: #38, #284, #45, #73. Facility census: 84.
Findings included:
a) Resident hand hygiene
On 02/21/23 at 11:17 PM, the surveyor arrived on the 2 South hallway to observe the noon meal pass. Resident #45 and Resident #284 were sitting at a table at the nursing desk. At 11:20 PM, Resident #38 was brought to the table via wheelchair. At 11:51 AM, Resident #73 was brought to the table via wheelchair.
On 02/21/23 at 11:37 AM, Employee #72 was observed delivering a meal tray to Resident #254 who was dining in her room. Hand hygiene was not offered to Resident #254.
At 11:41 AM, tray delivery was began by Restorative Aide (RA) #72 to the residents seated at the table at the nursing desk. Resident #284 received a tray at 11:41 AM. Resident #45 received a tray at 11:43 AM. Resident #38 received a tray at 11:47 AM. Resident #73 received a tray at 11:51 AM. None of the residents were offered hand hygiene before beginning their meals.
During an interview on 02/21/23, RA #72 stated Resident #38 had received hand hygiene because she had been toileted before being taken to the table. Employee #72 did not offer any information regarding hand hygiene for the remaining residents.
No further information was provided through the completion of the survey.
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Nov 2021
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
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Based on observation, and staff interview, the facility failed to provide a safe and comfortable reclining medical chair for Resident #71. This was a random opportunity for discovery. Resident Ident...
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Based on observation, and staff interview, the facility failed to provide a safe and comfortable reclining medical chair for Resident #71. This was a random opportunity for discovery. Resident Identifier: #71 Facility census 83.
Findings Included:
A) Resident #71
An observation on 11/08/21 at 11:58 a.m. found resident #71 sitting in a medical recliner chair in poor repair. The right arm of the medical reclining chair was missing vinyl and padding and rough, chipped wood was exposed.
During an interview on 11/08/21 at 12:00 p.m. Nurse Aide (NA) #60 confirmed that the right arm or the medical recliner chair was in poor repair, and stated she would complete a work order to have the medical recliner chair repaired.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure abuse and neglect policies were implemented for one (1) of one (1) residents reviewed for the care area of abuse. Resident i...
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Based on record review and staff interview, the facility failed to ensure abuse and neglect policies were implemented for one (1) of one (1) residents reviewed for the care area of abuse. Resident identifier: #37. Facility census: 83.
Findings included:
a) Resident #37
Review of Resident #37's medical records showed a note written on 10/14/21 at 3:57 PM which stated, Called to res [resident] room by cna [certified nursing assistant] noted bruise across the lower portion of residents back. res denies pain and is unable to tell this nurse how he acquired it. RN [registered nurse] supervisor notified, MPOA [medical power of attorney] notified MD [doctor] notified. (Note typed as written.)
Further review of Resident #37's medical records showed a note written on 10/29/21 at 8:15 PM which stated, CNA staff bruise to right buttock 1cm and a skin tear to left buttock cheek 0.5 while assisting resident in bed. while interviewing resident was unable to determine. Resident deny of any pain. Nurses supervisor notified. Left a message for MPOA to call facility. (Note typed as written.)
Risk Management Accident/Incident Investigative Reports regarding these incidents were completed on 10/14/21 and 10/29/21. The resident was unable to provide details of the incident. No staff interviews or statements were documented, other than the report of the nurse who assessed the bruises and skin tear.
Review of the facility's reportables did not show any reporting regarding Resident #37's bruise on the back discovered on 11/14/21 or the bruise and skin tear on the buttock discovered on 10/29/21.
The facility's policy entitled Abuse, Neglect, and Exploitation, implemented 04/20/17 and reviewed and revised 05/01/19 stated as follows:
- The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators .Physical marks such as bruises .
- When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted.
- Suspected abuse must be reported to the State Agency, the Ombudsman, and Adult Protective Services.
During an interview on 11/10/21 at 9:50 AM, Social Worker (SW) #144 stated she normally reported and investigated bruises of unknown origin as the facility's policy required. However, SW #144 stated she did not report or investigate Resident #37's bruise on the back discovered on 11/14/21 or the bruise and skin tear on the buttock discovered on 10/29/21. SW #144 gave no explanation as to why reporting and investigation was not done for these injuries.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to report bruises of unknown origin to the State Agency, Ombudsman, and Adult Protective Services. This failed practice had the potent...
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Based on record review and staff interview, the facility failed to report bruises of unknown origin to the State Agency, Ombudsman, and Adult Protective Services. This failed practice had the potential to affect one (1) of one (1) residents reviewed for the care area of abuse. Resident identifier: #37. Facility census: 83.
Findings included:
a) Resident #37
Review of Resident #37's medical records showed a note written on 10/14/21 at 3:57 PM which stated, Called to res [resident] room by cna [certified nursing assistant] noted bruise across the lower portion of residents back. res denies pain and is unable to tell this nurse how he acquired it. RN [registered nurse] supervisor notified, MPOA [medical power of attorney] notified MD [doctor] notified. (Note typed as written.)
Further review of Resident #37's medical records showed a note written on 10/29/21 at 8:15 PM which stated, CNA staff bruise to right buttock 1cm and a skin tear to left buttock cheek 0.5 while assisting resident in bed. while interviewing resident was unable to determine. Resident deny of any pain. Nurses supervisor notified. Left a message for MPOA to call facility. (Note typed as written.)
Risk Management Accident/Incident Investigative Reports regarding these incidents were completed on 10/14/21 and 10/29/21. Review of the facility's reportables did not show any reporting regarding Resident #37's bruise on the back discovered on 11/14/21 or the bruise and skin tear on the buttock discovered on 10/29/21.
During an interview on 11/10/21 at 9:50 AM, Social Worker (SW) #144 stated she normally reported bruises of unknown origin. However, SW #144 stated she did not report Resident #37's bruise on the back discovered on 11/14/21 or the bruise and skin tear on the buttock discovered on 10/29/21. SW #144 gave no explanation was to why reporting was not done for these injuries.
The facility's policy entitled Abuse, Neglect, and Exploitation, implemented 04/20/17 and reviewed and revised 05/01/19 stated as follows:
- The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators .Physical marks such as bruises .
- Suspected abuse must be reported to the State Agency, the Ombudsman, and Adult Protective Services.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to thoroughly investigate bruises of unknown origin. This failed practice had the potential to affect one (1) of one (1) residents rev...
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Based on record review and staff interview, the facility failed to thoroughly investigate bruises of unknown origin. This failed practice had the potential to affect one (1) of one (1) residents reviewed for the care area of abuse. Resident identifier: #37. Facility census: 83.
Findings included:
a) Resident #37
Review of Resident #37's medical records showed a note written on 10/14/21 at 3:57 PM which stated, Called to res [resident] room by cna [certified nursing assistant] noted bruise across the lower portion of residents back. res denies pain and is unable to tell this nurse how he acquired it. RN [registered nurse] supervisor notified, MPOA [medical power of attorney] notified MD [doctor] notified. (Note typed as written.)
Further review of Resident #37's medical records showed a note written on 10/29/21 at 8:15 PM which stated, CNA staff bruise to right buttock 1cm and a skin tear to left buttock cheek 0.5 while assisting resident in bed. while interviewing resident was unable to determine. Resident deny of any pain. Nurses supervisor notified. Left a message for MPOA to call facility. (Note typed as written.)
Risk Management Accident/Incident Investigative Reports regarding these incidents were completed on 10/14/21 and 10/29/21. The resident was unable to provide details of the incident. No staff interviews or statements were documented, other than the report of the nurse who assessed the bruises and skin tear.
During an interview on 11/10/21 at 9:50 AM, Social Worker (SW) #144 stated she normally investigated bruises of unknown origin. However, SW #144 stated she did not investigate Resident #37's bruise on the back discovered on 11/14/21 or the bruise and skin tear on the buttock discovered on 10/29/21. SW #144 gave no explanation as to why investigation was not done for these injuries.
The facility's policy entitled Abuse, Neglect, and Exploitation, implemented 04/20/17 and reviewed and revised 05/01/19 stated as follows:
- The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators .Physical marks such as bruises .
- When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for Resident #12. This was discovered for one (1) of one (1) reside...
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Based on record review and staff interview the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for Resident #12. This was discovered for one (1) of one (1) residents reviewed for the care area of hospice during the Long Term Care Survey Process (LTCSP). Resident identifier: #12 Facility census: 83
Findings included:
a) Resident #12
A review of the medical record for Resident #12 on 11/08/21, had a order for Hospice services with a start date of 02/25/21. Further review indicated the MDS with an assessment reference date (ARD) of 08/05/21, was not coded for hospice services under the Special Treatments section.
In an interview with MDS Coordinator on 11/09/21 at 1:25 PM, verified the Special Treatments section of the MDS assessment did not reflect hospice services being received by Resident #12.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on observations, record review and staff interview the facility failed to follow a physician's order for applying a compression glove for Resident #11. This was discovered for one (1) of one (...
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Based on observations, record review and staff interview the facility failed to follow a physician's order for applying a compression glove for Resident #11. This was discovered for one (1) of one (1) residents reviewed for limited range of motion during the Long Term Care Survey Process. Resident identifier: #11 Facility census: 83
Findings included:
a) Resident #11
Observations on 11/08/21 at 1:30 PM and on 11/09/21 at 2:00 PM, revealed the compression glove had not been applied to Resident #11's right hand.
A medical record review on 11/09/21, revealed an order for a compression glove to be placed on resident's right hand for edema in the morning and removed in the evening with a start date of 07/22/19.
An interview on 11/10/21 at 9:34 AM with registered nurse (RN) #38 verified staff was unable to locate the compression glove after searching Resident #11's room and the Physical Therapy Department. She also verified the physician's order had not been followed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure a pressure ulcer was correctly staged. This failed practice had the potential to affect one (1) of three (3) residents revie...
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Based on record review and staff interview, the facility failed to ensure a pressure ulcer was correctly staged. This failed practice had the potential to affect one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #51. Facility census: 83.
Findings included:
a) R#51
Review of Resident #51's medical records revealed wound weekly observation tools dated 11/04/21. Resident #51's right upper buttock wound was described as an original stage IV and current stage III.
The National Pressure Ulcer Advisory Panel (NPUAP) released a position statement in 2000 advising that pressure ulcer should not be reverse staged or down staged. The statement, which is available on-line, stated, Pressure ulcers heal to progressively more shallow depth, they do not replace lost muscle, subcutaneous fat, or dermis before they re-epithelialize . A Stage IV pressure ulcer cannot become a Stage III, Stage II, and/or subsequently Stage I.
During an interview on 11/10/21 at 10:25 AM, the Director of Nursing stated she agreed that Resident #51's right upper buttock pressure ulcer should not have been down staged from a stage IV to stage III.
No further information was provided through the completion of the survey.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
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Based on Resident Council interview, observations and staff interview, the facility failed to display the most recent State inspection survey results in a readily accessible area frequented by resid...
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Based on Resident Council interview, observations and staff interview, the facility failed to display the most recent State inspection survey results in a readily accessible area frequented by residents. It was discovered the State inspection survey was placed in an area not accessible to residents or family members. This had the potential to affect more than a limited number of residents. Facility census: 83
Findings included:
a) State Inspection Survey
In an interview with the Resident Council President on 11/09/21 at 11:00 AM, he was unaware of the location of the State inspection survey.
During an observation on 11/09/21 at 11:30 AM, with the Social Services Director (SSD), it was discovered the survey was not located in an area accessible, on the first floor to residents or family. The State inspection survey was located behind two (2) interlocking doors with a sign that read Keep Doors Closed. The SSD agreed the survey results were not located in an area readily accessible to residents or family.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to establish pharmaceutical procedures to promptly identify the loss or potential diversion of controlled medications. This failed pra...
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Based on record review and staff interview, the facility failed to establish pharmaceutical procedures to promptly identify the loss or potential diversion of controlled medications. This failed practice had the potential to all affect residents receiving controlled substances. Facility census: 83.
Findings included:
a) Medication Storage and Labeling
On 11/09/21 at 8:36 AM, the facility's controlled substance notebook and procedures were reviewed with Licensed Practical Nurse (LPN) #141. Controlled substances were in blister packs kept in a locked drawer in the medication cart. Blister packs, also called cards, had each tablet encased in a sealed, numbered compartment. Each resident had a separate blister pack for each controlled substance. Each blister pack had a corresponding tally sheet. The tally sheets were hole punched and kept in a notebook at the medication cart. When a controlled medication was needed, the tablet was removed from the blister compartment by the nurse. The medication removal was recorded on the tally sheet in the notebook, along with the number of tablets remaining in the blister pack.
A controlled substance count was performed every shift to recognize any discrepancies that may indicate documentation errors or possible drug diversion. LPN #141 stated that each shift change, the oncoming nurse and outgoing nurse counted the medications remaining on each card and ensured the number matched the amount documented on the tally sheets. LPN #141 stated the number of cards were not counted. LPN #141 was asked how it would be discovered if the tally sheet and card were removed since the number of cards aren't counted. LPN #141 stated she knew what narcotics should be in the cart.
During an interview on 11/09/21 at 10:56 AM , the Director of Nursing (DON) was informed of the situation described above. She was informed that if the tally sheet and card were removed, a period of time could pass before anyone realized the card of medications was gone. The DON stated she understood.
No further information was provided through the completion of the survey.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
The facility failed to label and date food items in the kitchen and pantry refrigerators. The facility also failed to pull exp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
The facility failed to label and date food items in the kitchen and pantry refrigerators. The facility also failed to pull expired food items from the pantry refrigerators. This had the potential to affect all residents who receive nutrients from the refrigerators. Facility Census 86.
Findings Included:
a) Kitchen and Pantry
On 11/08/21 at 09:14 AM an initial tour of kitchen was conducted with assistant dietary manager(ADM) #94. This tour found the following issues:
-- Cinnamon rolls in the kitchen reach in refrigerator dated 10/30/21 was expired. The ADM removed the Cinnamon Rolls immediately .
-- In the One (1) east pantry at 9:35 AM there were hot pockets with no name or date. The ADM removed them immediately.
-- In the two ( 2) south pantry at 9:42 AM found ego's with no date.
-- Pepperoni rolls with no date.
-- An expired ice cream dated 3/21/21. The ADM removed and discarded all items.
-- In the One (1) south pantry there was no name or date on an opened bottle of coke of cola.
-- No name or date on a creamy watery substance in small bowl.
-- An expired white substance in quart size [NAME] jar with date of 8/25/21. The ADM removed all items from the One (1) south pantry.
-- In the two (2) east pantry at 9:47 AM found soup with an expiration date of 10/24/21.
-- [NAME] beans, corn and tomatoes each in separate containers with no name or date.
-- Okra in zip lock bag with no name or date. All items were removed by the ADM and discarded.
The ADM agreed all food items should have been removed when being restocked by dietary staff.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview, the facility failed to ensure appropriate infection control standards...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview, the facility failed to ensure appropriate infection control standards for entry and screening procedures, during incontinence care for Resident #280, improper handling of dirty linens and hand hygiene during wound care for Resident #70. The facility also failed to ensure visitor screening for COVID - 19 was completed as required which increased the risk for spreading COVID-19. These were random opportunities for discovery. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident Identifiers: #280 and #70. Facility Census: 83.
Findings Included:
a) Resident #280
While incontinence care was being provided to Resident #280 on 11/08/21 at 9:13 AM, Nurse Aide #81 (NA) placed the soiled linens on the floor by the bed. NA #81 stated oh okay in reference to not placing soiled linens on the floor during incontinence care.
The Director of Nursing was notified on 11/10/21 at 8:20 AM. No further information was obtained during the Long-Term Care Survey Process.
b) room [ROOM NUMBER]
On 11/09/21 at 9:30 AM, soiled linens were found hanging on the safety bar in the bathroom beside the commode in room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #141 verified the linens were soiled and disposed of the linen in the inappropriate manner.
The Director of Nursing was notified on 11/10/21 at 8:20 AM. No further information was obtained during the Long-Term Care Survey Process.
c) Resident #70
An observation on 11/10/21 at 9:00 a.m. of Employee #44 performing treatment orders for Resident #70 found that the same sure prep pad (a skin protestant wipe) was used on the resident's left great toe pressure ulcer and then the right great toe pressure ulcer. Using the same sure prep pad could increase the potential for infection.
When asked if two (2) wipes should be used (one for each pressure ulcer), Employee #44 stated I usually use this small one for the toes and a bigger one for the heel. Employee #44 applied sure prep to left great toe, then right great toe, she then used another sure prep pad on the right heel, then removed Mepilex (a foam absorbent dressing) from the left heel, employee #44 used Alcohol Based Hand Rub (ABHR) after removal of the mepilex dressing and her gloves. This was the only time during all three (3) wound treatments hand hygiene was performed.
In an interview on 11/10/21 at 9:20 a.m. the Director of Nursing (DON) confirmed that a different sure prep pad should be used for each wound.
Record review of the facility's policy titled, Clean Dressing Change, showed each wound would be treated individually and the nurse should wash their hands and put on clean gloves.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • $5,000 in fines. Lower than most West Virginia facilities. Relatively clean record.
- • 41% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
- • 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.
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About This Facility
What is Sundale's CMS Rating?
CMS assigns SUNDALE NURSING HOME an overall rating of 4 out of 5 stars, which is considered above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Sundale Staffed?
CMS rates SUNDALE NURSING HOME's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 41%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sundale?
State health inspectors documented 31 deficiencies at SUNDALE NURSING HOME during 2021 to 2025. These included: 31 with potential for harm.
Who Owns and Operates Sundale?
SUNDALE NURSING HOME is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 100 certified beds and approximately 83 residents (about 83% occupancy), it is a mid-sized facility located in MORGANTOWN, West Virginia.
How Does Sundale Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, SUNDALE NURSING HOME's overall rating (4 stars) is above the state average of 2.7, staff turnover (41%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Sundale?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Sundale Safe?
Based on CMS inspection data, SUNDALE NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Sundale Stick Around?
SUNDALE NURSING HOME has a staff turnover rate of 41%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Sundale Ever Fined?
SUNDALE NURSING HOME has been fined $5,000 across 1 penalty action. This is below the West Virginia average of $33,129. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Sundale on Any Federal Watch List?
SUNDALE NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.