Salyersville Nursing and Rehabilitation Center

Inspectors wroteBased on interview, record review, and review of the facility's documentation and policy, the facility failed to ensure professional standards of nursing practice were maintained regarding the storage, tracking, and reconciliation of scheduled controlled substances for 1 of 1 residents sampled for narcotic medication out of the total sample of 10 (Resident (R)43).

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to immediately inform the resident's physician and/or Responsible Party (RP) as required for one (Resident (R) 1) of nine residents reviewed for medication administration. R1's Vimpat (an anti-convulsant medication used to treat seizures) was unavailable and not administered from 01/29/2026 until 02/01/2026. When the evening dose of Vimpat was administered on 02/01/2026, R1 received twice the ordered dose. The facility failed to immediately notify the resident's physician and representative of these medication errors. In addition, the facility failed to immediately notify the resident's RP when the resident was transferred to the hospital for evaluation after the 02/01/2026 medication overdose resulted in a change of condition.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 1) of nine residents reviewed for medication administration was free from significant medication errors. The facility failed to administer Vimpat (an anti-convulsant medication used to treat seizures) from 01/29/2026 until 02/01/2026, due to unavailability. When Licensed Practical Nurse (LPN) 1 administered the first (evening) dose of Vimpat on 02/01/2026, the resident received 200 milligrams (mg), rather than the 100 mg which was ordered. These errors are considered significant, as Vimpat has a narrow therapeutic window for safety, with high doses or incorrect administration having the potential to lead to increased seizures and/or severe, life-threatening events. [...]

Inspectors wroteBased on observation, interview, record review and facility policy, the facility failed to notify the Responsible Party (RP) when) a decision was made to transfer or discharge the resident from the facility to the hospital for one of 14 sampled residents. (Resident (R) 3).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a care plan was developed and implemented for four of 14 sampled residents (Resident #1 (R1), R3, #6, and R8.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents. On 07/28/2025, Resident (R)8 was in the dining room and hit R6; only one staff member, out of three scheduled, was present during the altercation.

Inspectors wroteBased on record review, interview, and review of state law, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Review of employee medical records revealed facility staff had not received tuberculosis (TB) testing within the required timeframe. Review of 902 [NAME] 20:205 revealed the administrative regulation established requirements for TB testing of healthcare workers in healthcare facilities or settings. The procedures were necessary to minimize the transmission of infectious TB disease among staff, patients, and residents of health facilities. Continued review revealed healthcare workers consisted of physicians, nurses, nurse aides, therapists, housekeeping, laundry, maintenance, and billing. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to protect residents from abuse for 2 of 84 sampled residents, (Residents (R)11 and R43).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to implement the facility's abuse policy for 2 of 84 sampled residents. (Residents (R)11 and R43).

Inspectors wroteBased on interviews, record reviews, and review of the facility's policy, the facility failed to implement its policies and procedures to ensure 2 of 84 sampled residents (R11) and (R12) were thoroughly investigated for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 87 sampled residents (Residents (R) 45, and 81).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for two of 37 sampled residents Resident (R) 26 and R110. Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR §483.25(b)(1) Pressure ulcers (F686) at the scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25(b)(1) Pressure ulcers (F686). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for one of 37 sampled residents (Resident (R) 26). Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.25(b)(1) Pressure ulcers (F686) at the scope and severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25(b)(1) Pressure ulcers (F686). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to utilize its resources effectively to ensure that its policies related to nutrition/hydration were implemented and failed to ensure that an effective system was in place to obtain accurate weights for each resident. In addition, the facility did not identify significant/severe weight changes and failed to implement interventions to ensure adequate nutrition/hydration and prevent serious adverse outcomes for 79 of 87 sampled residents (R1-R79). Immediate Jeopardy (IJ) was identified on 07/14/2025. It was determined to exist on 06/11/2025 in the areas of 42 CFR 483.25, Nutrition/Hydration Status Maintenance (F692) at the highest scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F692). [...]

Inspectors wroteBased on interview, record review, review of the facility's Administrator and Director of Nursing's Position Descriptions, review of the facility's policies and procedures, and review of the facility's abuse investigations, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's failure to have an effective system in place to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. [...]

Inspectors wroteBased upon interview, review of medical records, review of the facility's policy/procedures, the facility failed to ensure that its Quality Assurance and Performance Improvement Plan (QAPI) provided overall guidance to the facility; to provide excellence in quality of care and support quality of life through patient-centered care. The facility failed to implement an effective QAPI program to guide its operations and ensure the appropriate allocation of resources. As a result, the facility did not operate effectively or efficiently to achieve the highest practicable level of physical, mental, and psychosocial well-being for residents. This systemic failure caused or was likely to cause serious injury, impairment, or death to the resident. Immediate Jeopardy (IJ) was identified on 07/14/2005. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's documentation and policy, it was determined the facility failed to protect residents from abuse for three (3) of thirty-seven sampled residents (Residents (R) R12, R73, and R98.) Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a J and (F610), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600, and F610). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025.

Inspectors wroteBased on interview, record review and review of the facility's investigation and policy, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated to prevent further potential abuse for 2 of 37 sampled residents, (Residents (R)73 and R98). The facility's failure to ensure allegations of sexual and verbal abuse were thoroughly investigated to protect residents has caused or is likely to cause serious injury, impairment, or death to a resident if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a J and ( F610), at the highest scope and severity S/S of a J. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of thirty-seven sampled residents (R) R26. Review of R26's Care Plan for Impaired Skin Integrity, dated 02/10/2025, indicated that R26 would have a weekly skin assessment performed. However, the facility failed to provide evidence of weekly skin assessments.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure its residents received the necessary care and treatment by professional standards of practice and as required by the comprehensive person-centered care plan for one (Resident (R) 320) of 37 sampled residents. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care (F684) at the highest scope and severity S/S of a J and (F697), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F684, and F697). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on [DATE].

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure that pain management was provided to residents who required services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.25(k), Pain Management (F697) at the highest scope and severity S/S of a J and (F684), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 42 CFR 483.25(k), (F697, and F684). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. (Refer to F684)

Inspectors wroteBased upon interview, review of medical records, and review of the facility's policy/procedures, the facility failed to maintain complete and accurately documented clinical records. The facility failed to maintain complete and accurately documented clinical records for 79 of 116 residents (R1 - R79). Staff documented weights that had been falsified (made up). The fabricated and inaccurate weight records were used in clinical assessments related to residents' nutritional status, monitoring of weight changes, and care planning. These inaccurate records compromised the facility's ability to appropriately monitor residents' nutritional status and respond to weight changes. Documentation inconsistencies were found between recorded weights and residents' actual physical condition and intake records. [...]

Inspectors wroteBased on interviews, review of the facility's documents, and policy, it was determined the facility failed to ensure allegations of sexual and verbal abuse were reported to State Agencies and local law authorities immediately, but no later than two hours after the allegations were made for two of 37 sampled residents. (Resident (R) R73, and R98).

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure prescribed medications were administered as ordered by their physicians which resulted in missed doses of critical medications for 6 of 87 sampled residents (Residents (R) 4, R81, R82, R85, R86, and R87).

Inspectors wroteBased on interviews, observations, record review, and the facility's policy it was determined the facility failed to ensure proper evaluation and treatment for assistive devices related to maintaining hearing abilities for one of 37 sampled residents (R) (Resident #106).

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents received adequate supervision as necessary to prevent accidents for 1 of 6 residents sampled for smoking out of the total sample of 87, Resident (R) 45.

Inspectors wroteBased on observation, interview, and review of the facility policy it was determine the facility failed to store, serve and prepare food in accordance with professional standard for food service safety. Cups of Jell-O was stored in the walk-in refrigerator unlabeled and undated. An open bag of frozen breadstick was observed stored in the walk in freezer unlabeled and undated. Dust and food debris was observed on the top of the convection oven and the steamer.

Inspectors wroteBased on observation, interview, record review and a review of facility policy, it was determined the facility failed to maintain mechanical equipment in a safe operation condition. A non-functioning ice machine was observed in the kitchen.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure prompt efforts were made to resolve grievances for one (1) of forty-seven (47) sampled residents (Resident #117). On 01/09/19, Resident #117's family member voiced concerns to the Administrator and Director of Nursing (DON) that staff were not adequately suctioning secretions from Resident #117's tracheostomy (an opening in the neck to the windpipe). Resident #117 had been treated in the Emergency Department (ED) on 01/08/19 and diagnosed with Respiratory secretion[s] in [the] tracheostomy tube. According to the family member, the ED Physician who treated the resident on 01/08/19 stated the resident was not receiving appropriate tracheal suctioning. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop/implement comprehensive, person-centered care plans for four (4) of forty-seven (47) sampled residents (Resident #117, #21, #98, and #106). The facility failed to implement Resident #117's care plan, which stated staff were required to provide tracheostomy (an opening in the neck to the windpipe) care and administer insulin as ordered. On [DATE], at 7:00 PM staff failed to provide tracheostomy care (which includes suctioning) and at 11:00 PM, when the resident indicated he/she needed to be suctioned, staff only suctioned the resident's oral cavity but did not suction the resident's tracheostomy. Further, the facility failed to follow Resident #117's Physician's Orders for administration of Humulin R Insulin (regular, fast acting). [...]

Inspectors wroteBased on interview, closed record review, and review of facility policy, it was determined that the facility failed to ensure one (1) of forty-seven (47) sampled residents (Resident #117) received adequate supervision to prevent accidents. A review of Resident #117's admission assessment and a Physical Therapy Note dated [DATE], revealed the resident required assistance with transfers to/from bed/chair. The admission assessment revealed the resident also required extensive assistance with ambulation and toileting. However, on [DATE], at approximately 5:30 AM, staff observed Resident #117 transfer from bed to the bedside commode alone without offering to assist the resident. In addition, staff left the resident on the bedside commode unassisted. At approximately 6:30 AM, one hour later, staff found the resident on the floor, face down, unresponsive and not breathing. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure that three (3) of four (4) residents who required tracheostomy care and tracheal suctioning were provided such care, in accordance with physician's orders. Resident #117 had a tracheostomy (an opening in the neck to the windpipe) and had physician's orders for tracheostomy (trach) care every shift and suctioning as needed. On [DATE], the facility transferred Resident #117 to the hospital due to a low oxygen saturation and the resident returned to the facility on [DATE] at 4:23 AM, with a diagnosis of Respiratory secretion[s] in [the] tracheostomy tube. The resident's family member reported to the facility that the hospital physician stated staff were not suctioning the resident adequately. [...]

Inspectors wroteBased on interview, record review, and review of the facility's medication administration policy, it was determined the facility failed to ensure that one (1) of forty-seven (47) sampled residents (Resident #117) was free of significant medication errors. Resident #117 had a Physician's order for Humulin R insulin (regular, fast acting insulin that starts lowering your blood sugar within 30 minutes of being injected) to be administered every six (6) hours, but to hold the insulin for blood sugar results below 140 mg/dl (milligrams per deciliter). According to the resident's medication record, Humulin R insulin was due at 12:00 AM on [DATE]; however, interview with staff revealed the medication was not administered until 2:00 AM. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility Administrator failed to use resources effectively and efficiently to attain or maintain the highest practicable physical well-being for Resident #117. The facility failed to develop respiratory policies and procedures to ensure Resident #117 received respiratory care as needed. The Administrator also failed to investigate and respond to a grievance presented by a family member of Resident #117 on [DATE], regarding the resident's respiratory care. On [DATE], staff failed to provide respiratory care as ordered by the resident's physician and the resident was found not breathing on [DATE]. The resident was transferred to a hospital where he/she was pronounced dead as a result of Cardiopulmonary Arrest due to Upper Airway Obstruction. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure drugs and biologicals were stored in a manner that promoted safe administration for one (1) of forty-seven (47) sampled residents (Resident #61) and failed to ensure proper temperature control of drugs and biologicals. On [DATE], a medicated powder, which was applied to Resident #61's gastrostomy site, was expired. In addition, observations of the thermometer in the [NAME] Unit's medication room refrigerator and temperature monitoring logs for the refrigerator revealed temperatures were not being maintained within required parameters. Observation on [DATE] revealed the refrigerator's temperature was twenty-six (26) degrees Fahrenheit, with fourteen (14) medication capsules and eleven (11) vials of medication stored in the refrigerator.

Inspectors wroteBased on observation, interviews, and facility policy review it was determined the facility failed to provide drinks and other liquids consistent with resident preferences for four (4) of forty-seven (47) sampled residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the physician was notified of the need to alter treatment for three (3) of forty-seven (47) sampled residents (Resident #106, Resident #97, and Resident #111). Interviews and record review revealed the facility failed to notify Resident #106's Physician when the resident refused medications, was noncompliant with wearing oxygen, and when the resident's oxygen saturation levels were consistently below ninety percent (90%). In addition, Resident #97 and Resident #111 had physician orders to notify their physicians when their blood glucose levels were greater than 400 milligrams per deciliter (mg/dl). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of forty-seven (47) sampled residents (Resident #88) received necessary treatment and services, consistent with professional standards of practice, to prevent infection and promote healing of pressure ulcers. Observation of wound care for Resident #88 revealed staff failed to perform hand hygiene when removing soiled gloves and prior to donning new gloves while performing wound care for the resident.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to post the required nurse staffing data, which included the total numbers and actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants, on a daily basis at the beginning of each shift. Observations revealed the nurse staffing data was not posted at the beginning of the second shift on 01/15/19 and 01/16/19.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, it was determined the facility failed to ensure medical records were accurate for two (2) of forty-seven (47) sampled residents (Resident #21 and Resident #98). Review of Resident #21 and #98's Respiratory Medication Administration Records (MARs) for 01/09/19 at 7:00 PM revealed staff documented that tracheostomy care was provided for the residents. However, interview with staff revealed the care was not provided and the documentation was an error.