Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Brian Center Of Alleghany during CMS and state inspections, most recent first.
Two residents in an LTC facility experienced deficiencies in care planning. One resident did not have a care plan review for over a year despite multiple assessments, while another resident's significant weight loss was not addressed in their care plan. Staff interviews revealed failures in conducting required care plan meetings and updating care plans with individualized interventions.
Facility staff failed to implement proper infection control practices for a resident on contact precautions due to ESBL in urine, as a CNA did not wear the required PPE. Additionally, the facility did not follow CDC guidance for COVID-19 testing after an outbreak, failing to test all exposed staff on the recommended days. These deficiencies were noted during a review of the facility's infection control program.
A facility failed to properly document a Durable Do Not Resuscitate (DDNR) order for a resident with multiple health issues, including dementia and chronic kidney disease. The DDNR form lacked necessary signatures from the physician and the resident's authorized representative, instead containing signatures from two former registered nurses. Interviews with staff, including an LPN and the DON, revealed a lack of awareness and policy regarding the completion of DDNR forms.
A resident's baseline care plan was not developed within the required timeframe, leaving it incomplete and failing to guide staff in providing care. Interviews with staff revealed that the admitting nurse is responsible for completing the baseline care plan upon admission, but this was not done, violating the facility's policy.
A resident with PTSD, anxiety, depression, and OCD did not have a care plan addressing PTSD, despite being cognitively intact and having a history of trauma. The facility's Trauma Informed Care policy was not followed, as acknowledged by the MDS coordinator, leading to a deficiency noted by surveyors.
Facility staff failed to properly store nebulizer equipment for several residents, leaving it exposed to air instead of in bags as required for infection control. Additionally, a resident with multiple diagnoses received oxygen at a lower rate than prescribed by the physician. A nurse confirmed the discrepancy, noting that oxygen rates should be checked each shift. These issues were reported to the facility's administration.
A resident with PTSD, anxiety, depression, and OCD did not receive trauma-informed care as the facility failed to identify triggers for re-traumatization. The care plan lacked specific PTSD interventions, and staff actions exacerbated the resident's symptoms. The MDS coordinator was unaware of the need to identify triggers, contrary to the facility's trauma-informed care policy.
The facility failed to ensure accurate medication labeling on two units. A resident's sertraline was labeled with an incorrect dosage, not matching the current order, and opened over-the-counter medications lacked opening dates. The discrepancies were acknowledged by staff and presented to the DON and administrator.
The facility staff failed to properly store food in the main kitchen. An opened bulk bag of sugar was found in the dry storage room without labels indicating when it was opened or when it should be used by. The dietary manager acknowledged that the staff should have dated the bag with both an open date and a use-by date. This deficiency was communicated to the administrator and DON.
A facility failed to document offering an updated COVID-19 vaccine to a resident, as required by their policy. The resident's last recorded dose was in July 2022, and there was no evidence of an offer for the 2023-2024 vaccine. The DON confirmed the lack of documentation, and the resident could not recall being offered the vaccine but was interested in receiving it.
Deficiencies in Care Plan Review and Revision
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for two residents, leading to deficiencies in care planning. Resident #57, who was admitted with multiple diagnoses including COPD, emphysema, and depression, did not have a comprehensive care plan review or meeting conducted by the interdisciplinary team for over a year. Despite quarterly MDS assessments and a re-admission assessment, there was no documentation of care plan reviews. Interviews with the resident and staff revealed that care plan meetings were not held as required, and invitations for meetings were sent but not followed through. Resident #61, with diagnoses including diabetes, pressure ulcer, and chronic kidney disease, experienced significant weight loss that was not addressed in the care plan. Although the resident's weight loss was documented and interventions such as diet liberalization and therapy evaluation were noted, the care plan was not updated to include specific interventions for the weight loss. Interviews with nursing staff indicated a lack of individualized care planning for the resident's weight loss, despite recognition of the issue and attempts to address it through other means. The facility's policy required comprehensive care plans to be developed and reviewed within seven days of MDS completion and every 90 days thereafter. However, the facility failed to adhere to this policy for both residents, resulting in a lack of updated and individualized care plans. These findings were discussed with the facility's administrator and director of nursing during a meeting.
Infection Control Deficiencies in PPE Use and COVID-19 Testing
Penalty
Summary
The facility staff failed to implement proper infection control practices for Resident #18, who was on transmission-based precautions due to ESBL in urine. On January 22, 2024, a CNA entered the resident's room without donning the required personal protective equipment (PPE), specifically an isolation gown and gloves, as indicated by the contact precautions sign on the door. The CNA assisted the resident with toileting and only wore gloves, contrary to the facility's policy and the physician's order for contact isolation precautions. The CNA admitted to not knowing the full requirements of the precautions, highlighting a gap in staff training or communication. Additionally, the facility did not adhere to CDC guidance for COVID-19 testing following an outbreak on December 29, 2023. Despite conducting contact tracing, the facility failed to test all exposed staff members on the recommended days 1, 3, and 5 after exposure. The testing logs showed inconsistencies, with only a portion of the exposed staff being tested on the specified days. The Director of Nursing acknowledged the difficulty in testing staff who were off-duty, which contributed to the incomplete testing process. The facility's policies on isolation and COVID-19 prevention were reviewed, revealing discrepancies between the written procedures and their implementation. The failure to follow these protocols was brought to the attention of the facility administrator and the Director of Nursing, who also serves as the infection preventionist, during meetings on January 23, 2024. No further information or corrective actions were provided in the report.
Incomplete Documentation of DNR Order
Penalty
Summary
The facility failed to document a valid Durable Do Not Resuscitate (DDNR) order form for one resident, identified as Resident 59, in the survey sample. Resident 59 was admitted with multiple diagnoses, including diabetes, dementia, and chronic kidney disease, and was assessed with moderately impaired cognitive skills. A care plan meeting documented a decision to change the resident's code status to Do Not Resuscitate (DNR), with verbal consent from an authorized family member. However, the DDNR form was incomplete, lacking the required signatures of the physician and the resident's authorized representative. Instead, the form contained signatures from two registered nurses who were no longer employed at the facility. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and a social worker, revealed that the DDNR forms were not properly completed or signed. The LPN acknowledged the absence of signatures on the form and was unaware of why the physician had not signed it. The DON confirmed that the resuscitation status was reviewed during care plan meetings but did not know why the form was not signed by the provider. The social worker, who was not present when the DNR order was entered, stated that the forms should have been signed by the physician and the authorized representative. The facility lacked a specific policy on completing the DDNR form, contributing to the oversight.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility staff failed to develop and implement a baseline care plan for a resident within the required timeframe, leading to a deficiency. The resident was admitted to the facility, but the baseline care plan was not developed until several days later. Upon review, it was found that the baseline care plan was incomplete, with only the resident's name, allergies, and code status filled in, while other sections necessary for directing patient-centered care were left blank. Interviews with facility staff, including an LPN and the MDS nurse, revealed that the baseline care plan is supposed to be completed by the admitting nurse upon a resident's admission. This plan is intended to guide staff in caring for the resident until a comprehensive care plan is developed. The facility's policy mandates that an interim care plan be developed within 24 hours based on the initial assessment of each resident. However, this policy was not adhered to in the case of the resident in question, resulting in the deficiency.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a diagnosis of PTSD, among other mental health conditions. The resident, who was cognitively intact with a score of 12 on the MDS assessment, had a history of being in Vietnam, which was noted in a Trauma Informed Screen assessment. However, the care plan dated 12/19/23 did not include any specific interventions or accommodations for PTSD, aside from general instructions related to cognitive impairment, such as administering and monitoring medication and allowing the resident to make decisions without being rushed. During an interview on 1/23/24, the MDS coordinator acknowledged the absence of a PTSD-specific care plan after reviewing the facility's Trauma Informed Care policy and the resident's care plan. The policy emphasizes the importance of recognizing and responding to trauma in residents and incorporating this understanding into care plans to prevent re-traumatization. The deficiency was brought to the attention of the DON and Administrator during an end-of-day meeting, but no additional information was provided before the exit conference on 1/24/24.
Deficiencies in Respiratory Equipment Maintenance and Oxygen Administration
Penalty
Summary
The facility staff failed to maintain respiratory equipment in accordance with standards of practice for four residents. During a facility tour, it was observed that nebulizer masks and handheld mouthpieces for several residents were left on bedside tables exposed to air, rather than being stored in bags to prevent contamination. Interviews with nursing staff revealed that the nebulizers should be stored in bags for infection control purposes, as per the facility's policy. However, the staff had not adhered to this practice, resulting in the equipment being improperly stored. Additionally, the facility staff did not administer oxygen to a resident at the rate ordered by the physician. The resident, who had a diagnosis of obstructive and reflux uropathy, muscle weakness, cerebral infarction, and atrial fibrillation, was observed receiving oxygen at 1.5 liters per minute, despite a physician's order for 2 liters per minute. A registered nurse confirmed the discrepancy and acknowledged that the oxygen rate should be checked during each shift. These findings were communicated to the facility's administrator and director of nursing during the survey.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, anxiety, depression, and obsessive-compulsive disorder. The resident was assessed as cognitively intact with a cognitive score of 12. However, the facility did not identify specific triggers that could cause re-traumatization for the resident. The Trauma Informed Screen assessment did not provide detailed information related to the resident's PTSD, and the care plan lacked interventions and accommodations specific to PTSD, aside from general instructions for cognitive impairment. During an interview, the resident expressed that staff frustration and actions, such as moving belongings and offering relocation, exacerbated their anxiety and PTSD symptoms. A registered nurse, who was the MDS coordinator, was unaware of the need to identify triggers in the care plan. The facility's policy on trauma-informed care emphasizes understanding and responding to trauma to avoid re-traumatization, but this was not reflected in the care provided to the resident. The Director of Nursing and Administrator were informed of these findings during the end-of-day meeting.
Medication Labeling Deficiencies in Two Units
Penalty
Summary
The facility staff failed to provide accurate and timely medication labeling on two of five units, specifically the 100 hall and 200 hall. During a medication pass on the 200 hall, a resident's medication, sertraline, was labeled with an incorrect dosage that did not match the current medication order. The resident's clinical record indicated a physician's order for sertraline 100 mg daily, but the pharmacy label instructed to administer 75 mg. The registered nurse administering the medication acknowledged the discrepancy and noted that the pharmacy was supposed to send a new supply with the updated dosage. However, the previous supply with the discontinued dosage was not returned to the pharmacy, and the current supply for the 100 mg dose was not found in the medication cart. Additionally, during a medication storage review on the 100 unit, it was observed that an over-the-counter bulk bottle of Vitamin C and a bottle of Geri-Tussin cough syrup were opened without indicating the date they were opened. The LPN reviewing the medications confirmed that opened medications should have a date and subsequently removed the medications from the cart. The facility's policy requires that labels of over-the-counter drugs must contain the date opened and the expiration date. These findings were presented to the director of nursing and the administrator.
Improper Food Storage in Kitchen
Penalty
Summary
The facility staff failed to properly store food in the main kitchen, as observed during a survey. During an initial kitchen tour, an opened bulk bag of sugar was found in the dry storage room without any labels indicating when it was opened or when it should be used by. When questioned, the dietary manager acknowledged that the staff should have dated the bag with both an open date and a use-by date. This deficiency was communicated to the administrator and director of nursing, but no additional information was provided before the exit conference.
Failure to Document COVID-19 Vaccine Offer
Penalty
Summary
The facility staff failed to provide evidence that a resident was offered the updated COVID-19 vaccine. During a clinical record review, it was found that there was no documentation indicating that the resident had been offered the current 2023-2024 COVID-19 vaccine, with the last recorded dose being administered in July 2022. An interview with the facility's Director of Nursing (DON) confirmed the absence of such documentation, and the resident, when contacted, could not recall being offered the vaccine but expressed interest in receiving it. The facility's policy on COVID-19 vaccinations states that vaccines should be offered to residents when supplies are available, following CDC and FDA guidelines, and that documentation of the offer should be maintained. However, in this case, the facility did not have the necessary documentation to show compliance with this policy. The CDC recommends that everyone aged 5 years and older receive an updated COVID-19 vaccine, but the facility did not provide evidence that this recommendation was followed for the resident in question.
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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 Low Moor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Woodlands Health And Rehab Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Alleghany Health And Rehab | 4.7 mi | ★★★★★ | 5 | 0 |
| The Springs Nursing & Rehab Center | 12.9 mi | ★★★★★ | 0 | 0 |
| Brian Center Of Fincastle | 18.6 mi | ★★★★★ | 0 | 0 |
| White Sulphur Springs Center | 20.6 mi | ★★★★★ | 20 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.