Charleston Healthcare Center: Medical Record Errors - WV
The resident, identified in inspection records as Resident #152, had a documented allergy to betadine. That allergy was part of the resident's medical record. On January 20, 2025, a physician wrote an order for skin prep to treat a pressure injury on the resident's left great toe. Skin prep and betadine are not the same thing. The order was for skin prep.
What the wound nurse practitioner wrote was something else entirely.
Wound Nurse Practitioner #173 assessed the resident's pressure ulcer weekly and recorded treatment recommendations each time. On January 23, February 4, and February 10, the NP's notes stated that the wound was being treated with betadine. Not skin prep. Betadine. The substance the resident's own chart flagged as an allergen.
It wasn't until February 19 that NP #173's notes correctly reflected the actual treatment being used.
That's nearly four weeks of inaccurate documentation. Three separate assessments. Three separate opportunities to catch it.
The Director of Nursing confirmed the errors during an interview with inspectors on October 16 at 9:45 in the morning. The DON acknowledged that the wound NP's notes on January 23, February 4, and February 10 incorrectly indicated the resident was being treated with betadine. There was no dispute about what the records said. The records said the wrong thing, and the facility knew it.
Federal inspectors cited the facility under a standard requiring that medical records be complete, accurate, and maintained in accordance with accepted professional standards. The deficiency was tagged at a level of minimal harm or potential for actual harm, meaning inspectors determined the documentation failures had not caused confirmed injury to the resident. The citation covered one of three residents whose pressure ulcer care was reviewed during the complaint inspection.
What the inspection report does not resolve is the more unsettling question underneath the paperwork: if a nurse practitioner is documenting betadine on three consecutive weekly visits for a resident whose allergy to betadine is recorded in the same chart, what was actually happening at the wound?
The physician's order from January 20 called for skin prep. The NP's notes through February 10 said betadine. One of those is wrong. The Director of Nursing confirmed the notes were wrong, which means the order was being followed and the notes were not. But the notes are what other clinicians read. The notes are what gets reviewed when something goes wrong. The notes are the medical record.
A wound care note that says betadine when the treatment is skin prep is not a minor clerical slip in the context of a resident with a known betadine allergy. Any clinician picking up that chart, reading those three notes, would have reason to believe the resident was being exposed to something she couldn't tolerate.
Charleston Healthcare Center had 143 residents at the time of the inspection. The complaint inspection was conducted on October 16, 2025, eight months after the last of the three erroneous entries.
The wound NP's notes were corrected starting February 19. Whether anyone flagged the earlier entries, amended them, or documented why they were wrong is not addressed in the inspection report. The record shows three weeks of inaccurate documentation, a correction, and then eight months of silence before federal inspectors arrived and asked about it.
The Director of Nursing sat across from an inspector on a Thursday morning in October and confirmed what the chart already showed. The wrong treatment. The known allergy. The repeated entries.
Resident #152 had been discharged from the facility by the time inspectors reviewed the records. Whether the pressure ulcer on her left great toe healed, worsened, or required further treatment after discharge, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charleston Healthcare Center from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
CHARLESTON HEALTHCARE CENTER in CHARLESTON, WV was cited for violations during a health inspection on October 16, 2025.
The resident, identified in inspection records as Resident #152, had a documented allergy to betadine.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.