Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare Of Fentress County during CMS and state inspections, most recent first.
Kitchen Equipment Not Kept Sanitary: The cook-top stove/oven and double convection oven had visible dried food debris, including on the splash plate, burner pans, oven doors, and glass surfaces that blocked the view of food cooking. Although dietary staff had training on sanitation and equipment cleaning logs were complete, the CDM confirmed the equipment was not in a sanitary condition.
Incorrect MDS Weight Loss and Weight Gain Coding: A resident with pulmonary disease, spinal compression fractures, and protein-calorie malnutrition had MDS assessments that coded weight loss and weight gain without actual weights to support the percentages. The resident was cognitively intact on admission, but the record lacked documented weights showing the required change, and the MDS nurse confirmed the family did not provide actual weights and the assessments were coded incorrectly.
Failure to Prevent Pressure Injuries: A resident with diabetes, PVD, dementia, immobility, and incontinence had redness on admission and Braden scores showing risk for skin breakdown, but the record lacked resident-specific pressure injury prevention measures before a new stage 3 heel PI developed. The resident later developed a DTI on the other heel and new unstageable sacral/buttock PIs; the DON confirmed there was no documentation of heel off-loading until after the facility-acquired heel PI was found.
Expired milk was found in a resident’s personal refrigerator, and the refrigerator temperature was 51 degrees Fahrenheit, which was outside the safe range for food storage. The resident was cognitively intact and had diagnoses including HF, AKI, and cirrhosis. An LPN confirmed the milk was expired and the temperature was unsafe, and the DON stated housekeeping was responsible for cleaning, maintenance, and daily temperature checks.
Kitchen Equipment Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to ensure kitchen equipment was maintained in a sanitary working condition. Review of the Nutritional Services policy titled, Equipment, dated 9/2017, stated that all food service equipment would be clean, sanitary, and in proper working order, that equipment would be routinely cleaned and maintained according to manufacturer directions and training materials, and that food contact equipment would be cleaned and sanitized after every use. During the initial kitchen tour, the Certified Dietary Manager observed the cook-top stove/oven with smeared, dried, dark brown food debris on the splash plate behind the burners. The food debris collection pans under the burners had no aluminum foil lining and contained a moderate amount of partially burned food debris from multiple food groups. The oven doors also had dried brown/black food debris on the top of both doors, and the double convection oven had dried brown/black food debris on the inside of both upper doors. The glass portions of both the upper and lower units were covered with brown food debris that completely blocked the view of food cooking inside the convection oven. Dietary staff education and competencies reviewed showed staff had been trained on foodborne illness prevention, infection control, maintaining a sanitary kitchen, maintaining and operating kitchen equipment, and kitchen safety. Equipment cleaning logs for the prior 90 days were complete with no missing entries, yet the CDM stated the kitchen equipment was deep cleaned weekly and daily after use and confirmed the cook-top oven and double convection oven needed a thorough cleaning and were not currently in a sanitary condition.
Incorrect MDS Weight Loss and Weight Gain Coding
Penalty
Summary
The facility failed to accurately complete MDS assessments for weight loss and weight gain for one resident. The resident was admitted with diagnoses including pulmonary disease, spinal compression fractures, and protein-calorie malnutrition, and the admission MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The RAI Manual instructions reviewed in the report required asking the resident, family, or significant other about weight loss and weight gain over the past 30 and 180 days and calculating percentages based on actual weights, with coding only when the specified thresholds were met. The medical record showed no weight documented between the initial admission and the next recorded weight, and later weights were documented after the resident returned from the hospital. Despite the lack of actual weights showing a qualifying change, the admission MDS coded weight loss of 5% or more in the last month or 10% or more in the last 6 months as yes, not on a prescribed weight-loss regimen, and weight gain of 5% or more in the last month or 10% or more in the last 6 months as yes, on a physician-prescribed weight-gain regimen. A later 5-day MDS also coded weight loss of 5% or more in the last month or 10% or more in the last 6 months as yes, even though the record contained no documentation that the resident had experienced such weight loss or gain. During interview, the MDS nurse stated the resident's family said the resident had a weight gain followed by weight loss prior to admission, and confirmed there were no actual weights provided by the family to determine accurate percentages and that the MDS assessments were coded incorrectly.
Failure to Prevent Pressure Injuries
Penalty
Summary
The facility failed to provide resident-centered interventions to prevent pressure injury development for one resident with multiple risk factors for skin breakdown. Resident #10 was admitted with diagnoses including spinal vertebrae compression fracture, diabetes, peripheral vascular disease, and dementia, and the admission assessment showed mild cognitive impairment, partial/moderate assistance needed for bed mobility and transfers, non-ambulatory status, and frequent bladder incontinence with постоян bowel incontinence. The record also showed redness to the coccyx on admission and Braden scores of 13 and 15, indicating moderate to mild risk with additional major risk factors present. The care plan included general interventions such as turning and positioning, weekly skin checks, Braden assessments, pressure relieving mattress, and incontinence care, but the medical record and physician orders before 9/9/2025 showed no resident-specific measures to prevent pressure injury development from pressure. Resident #10 developed a new stage 3 pressure injury on the right heel, and the wound evaluation dated 9/9/2025 documented that the resident was observed with the injury and treatment was started. Physician orders for heel floating and heel protectors were initiated on that date. Later, the resident developed a new deep tissue injury on the left heel, and then new unstageable pressure injuries clustered on the buttocks/sacral area. The record also showed a later care plan problem related to refusal to turn and reposition, and a pressure ulcer letter of unavoidability stated the ulcers were considered unavoidable despite routine prevention interventions. During interview, the DON stated that off-loading with pillows, wedges, or heel boots is the standard practice to avoid heel pressure ulcers and confirmed there was no documentation that off-loading was provided until after the new facility-acquired heel pressure injury was found.
Expired Food and Unsafe Refrigerator Temperature
Penalty
Summary
The facility failed to meet safety requirements for personal refrigerator temperatures and for foods kept in date for one resident with a personal refrigerator. The facility policy titled, Foods Brought by Family/Visitors, revised 3/25/2024, stated that if a resident has a refrigerator in their room, temperatures will be maintained at an appropriate level. Resident #76 was admitted with diagnoses including Heart Failure, Acute Kidney Failure, and Cirrhosis of the Liver, and a quarterly MDS assessment showed a BIMS score of 14, indicating the resident was cognitively intact. During observation, the resident’s room contained a personal refrigerator with one unopened pint-sized milk carton on the top shelf that had an expiration date of 11/14/2025, and the refrigerator thermometer read 51 degrees Fahrenheit. An LPN confirmed the milk was expired and the temperature was out of the safe range for food storage. The LPN discarded the milk after notifying the resident and notified maintenance about the refrigerator temperature. The DON stated that housekeeping staff were responsible for cleaning, maintaining, and performing daily temperature checks and recording the information on a temperature log.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jamestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pickett Care And Rehabilitation Center | 14.4 mi | ★★★★★ | 0 | 0 |
| Clinton County Care And Rehabilitation Center | 20.9 mi | ★★★★★ | 0 | 0 |
| Overton County Health And Rehab Center | 21.8 mi | ★★★★★ | 0 | 0 |
| Huntsville Post-acute And Rehabilitation Center | 25.7 mi | ★★★★★ | 8 | 0 |
| Oneida Nursing And Rehab Center | 25.9 mi | ★★★★★ | 0 | 0 |
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