Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than West Virginia average
West Virginia average: 9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
119 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 119
Deficiencies: 2
Date: Sep 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with meal service timing and food safety standards in the facility.
Findings
The facility failed to ensure meals were served at consistent times, with dinner often served late, causing resident agitation. Additionally, the facility failed to store baking pans and dishes in a sanitary manner, risking food contamination.
Deficiencies (2)
Meals and snacks were not served at consistent times, with dinner served at least 21 minutes late on observed occasions.
Baking pans were stored wet (wet nesting) and dishes were dirty, risking contamination of food-contact surfaces.
Report Facts
Facility Census: 119
Trayline meal service time records: 33
Late meal service occurrences: 8
Inspection Report
Annual Inspection
Census: 108
Deficiencies: 13
Date: Jul 8, 2025
Visit Reason
The inspection was an annual survey to assess compliance with Medicare/Medicaid regulations and facility policies.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare Non-Coverage notices, grievance process issues, improper use of physical restraints, inaccurate care plans, failure to follow menus, food safety and storage violations, incomplete rehabilitative services, incomplete medical records, inadequate explanation of binding arbitration agreements, lack of certified infection preventionist participation in QAA meetings, failure to adhere to infection control protocols, and unsafe bed remote controls.
Deficiencies (13)
Failed to provide the required Notice of Medicare Non-Coverage (NOMNC) form to one resident prior to the end of Medicare Part A covered services.
Failed to ensure residents could exercise their right to file grievances anonymously and grievance forms were not readily available.
Failed to ensure resident was free from physical restraints that unnecessarily inhibited freedom of movement.
Failed to update the care plan to reflect a change in diet status for a resident.
Failed to ensure menus were followed for residents, including serving hot dogs without buns or condiments as ordered.
Failed to ensure food was served at an appetizing and safe temperature.
Failed to store food in accordance with professional standards including unlabeled, undated, and improperly sealed food items.
Failed to provide patient-centered rehabilitative services, including lack of speech therapy screening and inaccurate care plan reflecting diet orders.
Failed to ensure medical record was complete for a Physician Orders for Scope of Treatment (POST) form with no signature.
Failed to explain the Binding Arbitration Agreement accurately to residents or representatives.
Failed to have a certified Infection Preventionist attend and participate in Quality Assessment and Assurance meetings as required.
Failed to ensure staff adhered to infection control protocols including wearing required PPE for residents under Enhanced Barrier Precautions.
Failed to maintain bed remote controls in a safe operating condition; electrical tape was observed on a bed remote.
Report Facts
Facility census: 108
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Deficiencies cited: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DPT #155 | Director of Physical Therapy | Named in physical restraint and wheelchair procurement deficiency |
| Social Worker Designee #82 | Social Worker Designee | Named in failure to provide NOMNC form |
| Director of Social Services #76 | Director of Social Services | Named in grievance process deficiency |
| Administrator | Facility Administrator | Named in grievance and wheelchair procurement deficiencies |
| Corporate Registered Nurse #153 | Corporate Registered Nurse | Named in inaccurate care plan deficiency |
| Regional Dietary Manager #151 | Regional Dietary Manager | Named in food temperature deficiency |
| Regional Dietary Manager #152 | Regional Dietary Manager | Named in food storage deficiency |
| Assistant Dietary Manager | Assistant Dietary Manager | Named in food storage and utensil handling deficiencies |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Named in rehabilitative services deficiency |
| Interim Director of Nursing | Interim Director of Nursing | Named in rehabilitative services and POST form deficiencies |
| Back-Up Admission Coordinator | Back-Up Admission Coordinator | Named in binding arbitration agreement deficiency |
| Executive Director | Executive Director | Named in QAA meeting and infection preventionist deficiency |
| Unit Manager #64 | Unit Manager | Named in infection control protocol deficiency |
| Licensed Practical Nurse #90 | Licensed Practical Nurse | Named in infection control protocol deficiency |
| Nursing Assistant #107 | Nursing Assistant | Named in infection control protocol deficiency |
| Employee #32 | Named in bed remote control deficiency | |
| Maintenance Director | Maintenance Director | Named in bed remote control deficiency |
Inspection Report
Routine
Census: 108
Deficiencies: 3
Date: Jul 8, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with nutritional, food safety, and food service standards at Eagle Pointe Healthcare Center.
Findings
The facility failed to ensure menus were followed for residents, food was served at safe and appetizing temperatures, and food storage practices met professional standards. Multiple deficiencies related to menu adherence, food temperature, and improper labeling and dating of food items were observed.
Deficiencies (3)
Menus were not followed for Residents #64 and #2, including serving a hot dog on flat bread without condiments or proper bun.
Food was served at temperatures below standard, including buttered noodles at 112.0°F and broccoli at 102.9°F.
Food storage practices failed to meet standards, including unlabeled, undated, improperly sealed, and expired food items found in multiple storage areas.
Report Facts
Facility Census: 108
Food temperature: 125.1
Food temperature: 112
Food temperature: 102.9
Number of sandwiches without use by date: 6
Number of individual butter packages not dated: 9
Number of Rice Krispies Treats packages not dated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant (NA) #22 | Reported on menu adherence and confirmed unlabeled food items | |
| Assistant Director of Nursing (ADON) | Present during meal service and addressed missing hot dog buns | |
| Regional Dietary Manager #151 | Tested food temperatures and confirmed below standard temperatures | |
| Regional Dietary Manager #152 | Confirmed food storage deficiencies | |
| Assistant Dietary Manager | Confirmed food storage policies and deficiencies | |
| Licensed Practical Nurse (LPN) #87 | Confirmed unlabeled food items in nourishment pantry | |
| Licensed Practical Nurse (LPN) #73 | Confirmed unlabeled food items and stated intent to remove them |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 5
Date: Nov 22, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to assist a resident with transportation to their primary care physician, delayed necessary medical treatment, and issues with meal quality and timing.
Complaint Details
The complaint investigation revealed issues with transportation assistance for Resident #115, delayed medical treatment for worsening edema and congestive heart failure, and concerns about meal quality and timing affecting multiple residents.
Findings
The facility failed to promote resident self-determination by not assisting with transportation to the resident's primary care physician, delayed medical treatment for a resident with worsening edema and congestive heart failure, and failed to provide palatable, attractive, and timely meals. The resident experienced a weight gain of over 12 pounds in two months and was admitted to the hospital. Meal service issues included late meals, poor food quality, and inconsistent meal times.
Deficiencies (5)
Failed to assist resident with transportation to primary care physician, resulting in missed appointments and hospital admission.
Delayed necessary medical treatment for resident with shortness of breath, edema, and weight gain, leading to hospital admission for congestive heart failure.
Failed to ensure resident rooms and common areas were maintained at a comfortable temperature.
Failed to provide palatable, attractive, and appetizing food; meals were late, food quality was poor, and meal times were inconsistent.
Failed to ensure meals and snacks were served at times in accordance with resident needs and preferences.
Report Facts
Facility Census: 109
Resident Weight Gain: 12.4
Resident Weight: 370.4
Resident Weight: 354.4
Resident Weight: 366.2
Resident Weight: 363.8
Resident Weight: 356.8
Resident Weight: 356.8
Resident Weight: 356.2
Resident Weight: 358
Resident Weight: 353.4
Resident Oxygen Saturation: 98
Resident Pain Level: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP #131 | Nurse Practitioner | Examined Resident #115 and made medical orders; involved in transportation and treatment decisions |
| LPN #130 | Licensed Practical Nurse | Documented nursing notes regarding Resident #115's condition and medication administration |
| LPN #80 | Licensed Practical Nurse | Involved in communication about transportation and resident appointments |
| DON | Director of Nursing | Interviewed regarding transportation issues and x-ray results |
| MD #132 | Medical Director | Ordered resident to visit primary care physician |
| LPN #78 | Licensed Practical Nurse | Documented hospital admission status update for Resident #115 |
| LPN #68 | Licensed Practical Nurse | Documented nursing notes on cellulitis and resident condition |
| LPN #113 | Licensed Practical Nurse | Responded to resident complaint of feeling cold |
| Administrator | Facility Administrator | Interviewed regarding meal service issues and meal time consistency |
| NA #49 | Nurse Aide | Voiced concerns about meal times |
| NA #5 | Nurse Aide | Voiced concerns about meal times |
Inspection Report
Routine
Census: 112
Deficiencies: 5
Date: Feb 6, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, nutritional adequacy, food safety, and overall facility operations related to resident care and food service.
Findings
The facility failed to obtain daily weights as ordered for Resident #9, served inconsistent and improperly portioned meals, served food at unsafe temperatures, failed to provide evening snacks to diabetic residents, and maintained an unsanitary kitchen environment with inadequate cleaning and improper food holding temperatures.
Deficiencies (5)
Failed to obtain daily weights for Resident #9 as ordered by the physician.
Provided inconsistent portions of food not meeting nutritional needs.
Served food that was not palatable and at unsafe temperatures.
Failed to provide evening snacks to diabetic residents as needed.
Maintained an unsanitary kitchen environment and failed to keep kitchen equipment clean and sanitized; hot foods were not held at required temperatures.
Report Facts
Facility Census: 112
Resident #9 Weights: 10
Missed Weights: 5
Missed Night Snacks: 3
Missed Night Snacks: 5
Missed Night Snacks: 4
Food Temperatures: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #161 | Corporate Registered Nurse | Acknowledged failure to obtain weights and provide night snacks; involved in interviews regarding findings |
| RN #31 | Registered Nurse | Acknowledged use of wrong scale and lack of documentation for weight loss event |
| Cook #118 | Observed serving inconsistent food portions and acknowledged responsibility for steam table water level | |
| Culinary Director | Culinary Director (CD) | Acknowledged wrong scoop usage, food temperature issues, and unsanitary kitchen conditions |
| LPN #130 | Licensed Practical Nurse | Provided information about snack availability and resident requests |
| NA #11 | Nurse Aide | Provided information about snack availability and resident requests |
| Registered Dietician | Registered Dietician | Discussed expectations for snack offerings and food service |
| Administrator | Facility Administrator | Acknowledged food service and kitchen sanitation issues during interviews |
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 1
Date: Sep 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use and care of feeding tubes in residents, specifically to ensure feeding tubes are used only when medically necessary and that appropriate care is provided.
Findings
The facility failed to ensure Resident #3 received an adequate amount of nutrition via feeding tube to maintain acceptable nutritional parameters, resulting in significant weight gain that was not desired. The Director of Nursing verified the facility did not maintain acceptable nutrition parameters to prevent this weight gain.
Deficiencies (1)
Failed to ensure Resident #3 received an adequate amount of nutrition to maintain acceptable parameters of nutrition via feeding tube.
Report Facts
Facility census: 114
Resident #3 weight measurements: 164.4
Resident #3 weight measurements: 160.6
Resident #3 weight measurements: 153.2
Resident #3 weight measurements: 157
Resident #3 weight measurements: 150.6
Resident #3 weight measurements: 152
Weight gain: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interview verified facility did not maintain acceptable nutrition parameters for Resident #3 |
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The visit was a focused infection control survey to assess the facility's infection prevention and control program, specifically regarding resident handwashing practices during meal times.
Findings
The facility failed to ensure residents on the north hall received hand hygiene prior to or during the lunch meal tray pass, with staff confirming lack of hand wipes at the time. The Director of Nursing acknowledged that wipes are available and should be used at all meal passes.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program related to resident handwashing during meal times.
Report Facts
Facility census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse #54 | License Practical Nurse | Interviewed regarding resident hand hygiene during lunch meal |
| Nurse Aide #64 | Nurse Aide | Interviewed regarding availability and use of hand wipes for residents |
| Director of Nursing | Director of Nursing | Interviewed about facility's use of hand wipes at meal passes |
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The inspection was conducted as a Focused Infection Control Survey to evaluate the facility's infection prevention and control program, specifically regarding resident handwashing practices during meal times.
Findings
The facility failed to establish and maintain an effective infection prevention and control program related to resident hand hygiene prior to or during meal tray passes. Observations and staff interviews confirmed residents did not receive hand hygiene before lunch on the north hall, and staff lacked hand wipes at the time.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program ensuring resident hand hygiene prior to or during meal tray passes.
Report Facts
Facility census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse #54 | License Practical Nurse | Interviewed regarding resident hand hygiene practices during lunch meal |
| Nurse Aide #64 | Nurse Aide | Interviewed regarding availability and use of hand wipes for residents |
| Director of Nursing | Director of Nursing | Interviewed about facility's use of hand wipes at meal passes |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 18
Date: May 26, 2023
Visit Reason
The inspection was conducted due to a complaint regarding Resident #19's motorized wheelchair being disabled by the facility, which affected her mobility and caused psychological harm.
Complaint Details
The complaint investigation was triggered by concerns about Resident #19's motorized wheelchair being disabled by the facility, resulting in loss of mobility and psychological harm. Additional complaints involved failure to notify family of medical changes, privacy violations, unresolved grievances, abuse allegations, and inadequate care.
Findings
The facility failed to provide Resident #19 with reasonable accommodation for her mobility needs by disabling her motorized wheelchair, resulting in psychological harm. The facility also failed to provide timely and appropriate psychotherapy services. Additional findings included failure to notify family of medical changes, privacy violations, inadequate environment, unresolved grievances, delayed abuse reporting and investigation, incomplete assessments, inconsistent care plans, inadequate pain management, food safety violations, incomplete medical records, and failure to conduct COVID-19 testing per guidelines.
Deficiencies (18)
Failed to provide Resident #19 with reasonable accommodation for her motorized wheelchair, causing psychological harm.
Failed to notify representative/family of medical changes for Resident #171.
Violated resident privacy by requiring residents to open packages in front of staff.
Failed to provide a safe, clean, comfortable environment; poor lighting and damaged window blinds.
Failed to promptly resolve grievances and keep residents apprised of progress.
Failed to timely report suspected abuse and allowed alleged perpetrator to continue working.
Failed to notify State Ombudsman of resident transfer to acute care facility for Resident #55.
Failed to provide bed hold policy to resident or representative upon transfer to acute care facility for Resident #55.
Failed to complete significant change MDS assessment after resident began hospice services for Resident #93.
Failed to ensure PASARR screening reflected new psychiatric diagnoses for Resident #68 and #112.
Failed to develop and implement comprehensive care plans meeting residents' needs for Residents #112, #47, #51, #39, and #66.
Failed to ensure appropriate pain management and consistent pain assessment for Resident #66.
Failed to maintain medications properly; multi-dose PPD vial not dated when opened.
Failed to conduct COVID-19 testing of staff and residents per CDC guidelines during outbreak.
Failed to maintain medical records complete and accurate for Residents #101, #47, #34, #51, and #170.
Failed to provide appropriate treatment and services to Resident #19 with mental disorder; psychotherapy sessions not provided as recommended.
Failed to ensure food safety; unlabeled and expired food items, incomplete temperature logs, uncovered water pitchers, improperly stored utensils, and unclean ice machine filters.
Failed to maintain ice machines with required one-inch air gap for drainage in North Nourishment Room and Main Dining Room.
Report Facts
Facility Census: 110
Residents reviewed: 26
Residents affected by abuse deficiency: 4
Residents affected by care plan deficiency: 5
Residents affected by medical record deficiency: 5
Residents affected by pain management deficiency: 1
Residents affected by PASARR deficiency: 2
Residents affected by significant change MDS deficiency: 1
Residents affected by hospitalization deficiency: 3
Dates missing temperature logs: 30
Staff not tested for COVID-19 during outbreak: 9
Positive residents during outbreak: 53
Positive staff during outbreak: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #82 | Social Worker | Involved in abuse investigation, grievance handling, and psychotherapy referral for Resident #19 |
| Occupational Therapist #172 | Occupational Therapist | Evaluated Resident #19's capacity and motorized wheelchair use |
| Nursing Home Administrator | Administrator | Provided information on wheelchair incident and abuse investigation |
| Nursing Assistant #75 | Nursing Assistant | Alleged perpetrator of verbal abuse to Resident #97 |
| Resident Service Director #24 | Resident Service Director | Handled grievances and abuse allegations |
| Licensed Practical Nurse #47 | Licensed Practical Nurse | Confirmed medication storage issue with PPD vial |
| Director of Nursing | Director of Nursing | Confirmed multiple deficiencies including care plan, pain management, and transfer notification |
| Culinary Director | Culinary Director | Acknowledged food storage and kitchen sanitation deficiencies |
| Infection Preventionist | Infection Preventionist | Failed to maintain proper COVID-19 testing and contact tracing |
| Social Worker #136 | Social Worker | Involved in abuse grievance and reporting |
| Director of Plant Maintenance | Director of Plant Maintenance | Unaware of ice machine drainage requirements |
| Minimum Data Set Register Nurse #57 | MDS Nurse | Interviewed regarding PASARR and care plans |
| Minimum Data Set Licensed Practical Nurse #131 | MDS LPN | Interviewed regarding PASARR and care plans |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Date: May 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the representative/family of medical changes and inadequate pain management for residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify the Power of Attorney of medical changes for Resident #171 and inadequate pain management practices for Resident #66.
Findings
The facility failed to notify the Power of Attorney for Resident #171 of medical order changes and failed to ensure consistent pain management and pain level assessment for Resident #66, including incomplete documentation on the Medication Administration Record.
Deficiencies (2)
Failure to notify the representative/family of medical changes for Resident #171.
Failure to provide safe, appropriate pain management and inconsistent pain level assessment for Resident #66.
Report Facts
Residents affected: 1
Residents affected: 1
Medication administrations: 7
Pain assessments: 2
Pain assessments missed: 5
Facility census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed regarding notification failures for Resident #171 | |
| Director of Nursing (DON) | Interviewed regarding pain management and documentation deficiencies for Resident #66 |
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 9
Date: Feb 23, 2022
Visit Reason
The inspection was conducted as part of the Long-Term Care Survey process to assess compliance with regulatory requirements for Eagle Pointe Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to ensure proper documentation of advance directives, employee background checks, accurate resident assessments, catheter care, medication regimen reviews, psychotropic medication use, medication labeling, kitchen sanitation, and vaccination consent procedures.
Deficiencies (9)
Failed to ensure a resident's Physician Orders for Scope of Treatment (POST) form was signed and dated by the preparer.
Failed to ensure an employee hired had not been found guilty of abuse, neglect, exploitation or theft.
Failed to ensure a complete and accurate Minimum Data Set (MDS) Assessment for a resident.
Failed to provide appropriate catheter care to residents with indwelling catheters to prevent urinary tract infections.
Failed to maintain attending physician review of medication regimen for residents on unnecessary medications.
Failed to ensure residents' drug regimens were free from unnecessary psychotropic medications and failed to implement non-pharmacological interventions prior to PRN medication use.
Failed to ensure medications were stored and labeled in accordance with professional principles; an opened insulin pen was not dated.
Failed to maintain kitchen sanitation; dietary aide was not wearing a beard guard in the kitchen service area.
Failed to ensure residents and/or their representatives had the opportunity to refuse the annual influenza vaccine.
Report Facts
Facility census: 104
Residents reviewed for advance directives: 19
Employees reviewed for background checks: 6
Residents reviewed for medication regimen: 5
Residents reviewed for catheter care: 3
Dates catheter care missed for Resident #48: 6
Dates catheter care missed for Resident #58: 6
Dates PRN psychotropic medication administered to Resident #91: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HR #52 | Human Resources | Interviewed regarding employee fingerprinting and hiring compliance |
| LPN #62 | Licensed Practical Nurse | Confirmed insulin pen was not dated when opened |
| MDS Coordinator #104 | Confirmed inaccurate Minimum Data Set assessment | |
| DON (Director of Nursing) | Director of Nursing | Acknowledged catheter care deficiencies and lack of documentation for psychotropic medication use |
| Administrator | Acknowledged issues with employee fingerprinting and medication regimen review | |
| Dietary Manager (DM) | Dietary Manager | Acknowledged dietary aide not wearing beard guard |
| IPRN #13 | Infection Preventionist/Registered Nurse | Confirmed lack of consent for annual influenza vaccine refusals |
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