Charleston Healthcare: Failed to Notify Family - WV

Charleston Healthcare Center's violation occurred during the resident's third hospital transfer in four months. Federal inspectors found the facility properly handled the first two transfers in late January and February, when the resident still had decision-making capacity.

Everything changed on March 2nd.

That day, the resident lost capacity to make medical decisions. Two days later, on March 4th, the resident fell at the facility and required hospital transfer. Staff provided transfer and bed-hold notices to the resident, following the same procedure they had used for the previous transfers.

But the law had changed with the resident's condition.

Once a resident loses decision-making capacity, facilities must notify their designated representative or power of attorney in writing about any transfer or discharge. The facility must explain the reason for the transfer and provide a copy of the bed-hold notice to the representative, not the incapacitated resident.

Charleston Healthcare Center has 145 residents. Inspectors reviewed four residents' transfer records during their survey and found the violation affected one person, identified as Resident #19 in the inspection report.

The resident's transfer history tells the story of declining health. The first hospital stay lasted from January 29th to February 3rd. The second ran from February 22nd to March 1st. During both transfers, the resident received proper notifications because they retained decision-making capacity.

The third transfer, from March 4th to March 10th, occurred after the resident's capacity loss but before the facility adjusted its notification procedures.

Federal bed-hold policies exist to protect residents and families during hospital stays. When nursing home residents require acute care, they risk losing their bed if they don't understand their rights or if families aren't informed about hold policies and payment requirements.

The violation carries particular weight because it occurred during a vulnerable period. The resident had already experienced two hospitalizations in five weeks, suggesting serious health complications. The fall that triggered the third transfer likely represented another decline in condition.

Facilities must track residents' decision-making capacity and adjust their procedures accordingly. The two-day gap between the resident's capacity loss and the fall created a narrow window where staff needed to recognize the change and update their notification protocols.

The Director of Nursing reviewed the violation with inspectors on April 2nd at approximately 10:40 AM. The inspection report doesn't indicate whether the facility had policies in place to monitor capacity changes or train staff on notification requirements for incapacitated residents.

Charleston Healthcare Center's failure represents a common challenge in long-term care. Residents' cognitive abilities can fluctuate or decline rapidly, especially during periods of acute illness requiring multiple hospitalizations. Staff must remain alert to these changes and ensure proper notifications reach the right people.

The violation occurred despite the facility's demonstrated ability to handle transfer notifications correctly. The first two transfers show staff understood the basic requirements and had systems in place to provide proper notices when residents retained capacity.

Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the impact on families can be significant when they're excluded from critical medical decisions and transfer notifications.

The bed-hold notice violation highlights broader issues in nursing home communication. When residents lose decision-making capacity, families become essential partners in care decisions. Excluding them from transfer notifications can leave relatives uninformed about their loved one's condition and unaware of their rights regarding bed holds and facility readmission.

The resident's pattern of repeated hospitalizations and declining capacity illustrates the complex medical needs that nursing homes must navigate while maintaining compliance with federal notification requirements.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Charleston Healthcare Center from 2026-04-02 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Charleston Healthcare Center
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