Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Fayetteville Healthcare Center during CMS and state inspections, most recent first.
A resident’s discharge return not anticipated MDS incorrectly coded the discharge destination as a short-term general hospital, even though a nursing note documented discharge home with home health. The DON later confirmed the resident was discharged home and that the MDS was coded incorrectly.
A resident’s comprehensive care plan was not revised to reflect the resident’s LTC goal. Record review showed the plan still contained conflicting active entries, including one for discharge to home when abilities improved and another stating no plans for discharge due to LTC placement. The SW, Administrator, and DON acknowledged the outdated and conflicting care plan entries.
A resident with a POST form and DNR order was found collapsed, cyanotic, and pulseless, yet CPR was started before EMS arrived. The record showed the resident had chosen no CPR if pulseless and apneic, and EMS later verified the DNR status and stopped life-saving measures.
A nurse aide passed lunch trays to two residents sharing a room without first offering hand sanitation, then left the room. When questioned, she retrieved hand wipes and returned to ask if they had eaten yet and whether they wanted to wipe their hands. Facility policy required hand hygiene before eating and before tray pass.
Staff failed to promptly remove dirty dishes and old food from the dining room after a meal, leaving items such as tea, milk, and macaroni and cheese unattended, with a meal ticket still present. In a separate incident, an oxygen cannula, tubing, and a soiled bath basin were found on the floor in a resident's room, with the resident noted to be confused and unable to explain the presence of these items. These lapses were observed and confirmed by LPNs and a nurse aide.
A resident was observed sitting in a wheelchair wearing only a brief and no shirt in front of an open bathroom door to the hallway while a nurse aide provided catheter care and prepared for toileting. The DON confirmed the door should have been closed, indicating a failure to maintain the resident's dignity and privacy during ADL care.
A resident with a history of behavioral disturbances and multiple chronic conditions was transferred to acute care following inappropriate sexual behavior. After being medically and psychiatrically cleared, the resident was not permitted to return, and the facility did not have active discharge planning or recent referrals in place. Facility leadership confirmed the decision to deny return without implementing further discharge planning or supervision.
A resident's medical record contained incorrect dates on transfer forms related to multiple transfers to an acute care facility. The DON confirmed that the errors occurred because nurses sometimes did not review the dates on the forms.
Surveyors found hallways blocked by wheelchairs, geri chairs, mechanical lifts, a portable AC unit, and a linen cart, preventing direct access through the corridor. An LPN confirmed the obstruction, which had the potential to affect a small number of residents.
A resident in an LTC facility was prescribed Macrobid for a UTI despite the bacteria being resistant to it, as per the urine culture. The resident's symptoms persisted, and she was later hospitalized with sepsis. The facility's antibiotic stewardship program was not properly implemented, as the Infection Preventionist did not verify the physician's order against the culture results.
The facility failed to ensure proper disposal of garbage and refuse by leaving the dumpster lid open, as observed during a kitchen inspection. The Nursing Home Administrator confirmed the lid should have been closed, potentially affecting all 56 residents.
A CNA was observed preparing a thickened drink for a resident by holding the glass with bare hands on the rim, which is against safe food handling practices. The CNA acknowledged the mistake and the CM RN disposed of the drink.
A facility failed to obtain the necessary signature from a resident's Medical Power of Attorney (MPOA) for an advance directive. Although verbal confirmation was received, the required signature on the West Virginia Physician Order for Scope of Treatment (WV POST) form was not secured. The Assistant Director of Nursing acknowledged this oversight during an interview.
The facility failed to maintain a homelike environment for two residents. A resident's wardrobe was missing a drawer face, and another resident's privacy curtain was missing hooks, causing it to hang improperly. These deficiencies were confirmed by the RN Unit Manager.
A facility failed to implement abuse prevention measures after an incident where a resident allegedly attempted inappropriate contact with another resident. Although initial one-on-one supervision was ordered, it was not documented or continued until the following day, leaving residents unprotected. The DON could not provide evidence of continued supervision.
A facility failed to report and investigate an incident where a resident threw a cup of water at another resident. The incident was not documented in the facility's logs, and the Administrator confirmed no investigation was initiated. The resident involved had a care plan note indicating a history of similar behaviors.
A facility failed to accurately complete the MDS Assessment for a resident upon discharge, incorrectly recording the discharge location as a Short-Term General Hospital instead of Home/Community. The error was made by the SW, who acknowledged it as a typographical mistake during an interview.
The facility failed to update the PASARR for two residents after they were diagnosed with major depressive disorder. One resident's PASARR was not updated after a diagnosis in March, and another resident's PASARR was not updated following a diagnosis in August. The social worker confirmed the oversight and mentioned efforts to update the necessary PASARRs.
A facility failed to include all appropriate diagnoses on a resident's PASARR form. The form only listed dementia, while the resident also had bipolar disorder, depression, and generalized anxiety disorder upon admission. This oversight was confirmed by a social worker during the survey process.
A resident with an ileostomy was served corn, a food she should avoid, due to the facility's failure to include diet restrictions in her care plan. Despite her tray ticket indicating an alternate vegetable, the care plan lacked necessary dietary guidelines. The Registered Dietician and DON confirmed the oversight.
The facility failed to update care plans for three residents following changes in diagnoses and medications. A resident's care plan did not reflect a new diagnosis of major depressive disorder. Another resident's care plan was not updated after discontinuation of Seroquel and Melatonin. A third resident's care plan still listed Zoloft despite its discontinuation. These issues were confirmed by the DON.
A facility failed to act on a physician's order for a resident, resulting in a delay in treatment. The resident had an order for hemoccult stool tests due to an abnormal lab result, but only one sample was obtained, which tested positive for blood. Despite new orders to monitor and follow up with the in-house physician, there was no documentation of physician notification or further sample collection. The DON acknowledged the delay in obtaining the sample and lack of action.
A resident's call light went unanswered for 40 minutes due to insufficient nursing staff, as their assigned aide was reassigned to provide one-on-one care for another resident. The facility failed to document staff reassignments, resulting in delayed care and unmet needs.
A facility failed to monitor a resident for side effects of antianxiety, antidepressant, and mood-stabilizing medications as ordered, and also did not monitor behaviors as required. The resident had specific orders for monitoring side effects and behaviors every shift, but records showed missing entries on multiple days and shifts. This deficiency was acknowledged by the DON during the survey.
A resident received incorrect medications due to a new nurse's unfamiliarity with the residents, leading to a significant medication error. The nurse administered the resident's roommate's medications instead of the prescribed ones. The facility's policy emphasizes the five rights of medication administration, but the nurse had not been educated on these rights.
A resident with an ileostomy was served corn, which she should avoid, during a meal at the facility. Her tray ticket indicated she should have received a squash medley, but this was overlooked by the dietary manager. The resident's care plan did not include her special dietary needs, and the Registered Dietician confirmed the error.
The facility failed to accurately document a resident's discharge and complete another resident's capacity form. A resident was discharged against medical advice without proper documentation, and the facility's census list inaccurately coded the discharge. Another resident's capacity form was incomplete, lacking a clear indication of decision-making capacity. These errors highlight deficiencies in maintaining accurate medical records.
The facility failed to ensure residents understood binding arbitration agreements before signing. One resident did not recall signing the agreement, while another signed while incapacitated. The social worker responsible did not verify capacity, assuming it due to the absence of a capacity form.
The facility experienced significant staffing shortages, resulting in unmet resident needs such as long wait times for assistance, inconsistent water delivery, and missed showers. Residents reported these issues during interviews, and observations confirmed staff inaction during night shifts. The facility's staffing levels often fell below the required number of nurse aides, contributing to the deficiency.
The facility failed to consistently provide water to its residents, as evidenced by a resident's report of not receiving water despite requests and observations confirming the absence of water delivery. During a resident council meeting, multiple residents expressed similar concerns about the inconsistency in water delivery, indicating a broader issue affecting hydration provision.
The facility failed to ensure food safety and sanitation, leading to immediate jeopardy for residents. Observations revealed food was not cooked to the required temperature, and the kitchen was unsanitary with improperly labeled and expired items. These deficiencies placed all residents at risk of foodborne illnesses.
The facility failed to keep the janitor's closet door in the dining room locked, exposing residents to hazardous chemicals. Observations showed the door could be easily opened, and the Maintenance Director confirmed that items hanging on the door sometimes prevented it from latching. The closet contained chemicals with significant risks, requiring locked storage.
A facility failed to thoroughly investigate an incident where a resident was physically abused by another resident during the night shift. Although the victim used a call light to summon help, no statements were obtained from the night shift staff who responded. The Director of Nursing, Social Worker, and Nursing Home Administrator acknowledged the oversight in not collecting these crucial statements.
A resident was reportedly hit in the head multiple times by another resident, but the facility failed to conduct the required neurological assessments. The incident was documented, but a review of the medical record showed no assessments were completed, which was confirmed by the DON. This was contrary to the facility's policy on neurological checks for head injuries.
Incorrect Discharge Destination Coded on MDS
Penalty
Summary
The facility failed to ensure accurate MDS assessments for Resident #60. The resident’s discharge return not anticipated MDS assessment, with an ARD of 01/16/26, coded the discharge destination as a short-term general hospital. However, a nursing note written on 01/16/26 at 3:28 PM stated that Resident #60 was discharged home with home health. On 03/10/2026 at 3:05 PM, the DON confirmed that Resident #60 was discharged home and that the discharge MDS was incorrectly coded regarding the discharge destination.
Care Plan Not Revised to Reflect Resident’s Long-Term Care Goal
Penalty
Summary
The facility failed to revise Resident #6’s comprehensive care plan to reflect the resident’s choice of long-term care goal. Record review showed the care plan still included two conflicting active entries: one stating the resident had plans to discharge to home when there was overall improvement in abilities, initiated and revised on 02/08/19, and another stating the resident had no plans for discharge secondary to long-term care placement in the facility, initiated and revised on 08/28/24. During interview, the Social Worker stated the initial focus should have been resolved but continued to appear on the care plan as active. The Administrator and DON acknowledged that the care plan contained both a plan to return to the community and a plan for long-term care, and that the care plan needed to be revised.
CPR Initiated Despite Resident DNR/POST Order
Penalty
Summary
The facility failed to honor a resident's POST form and DNR order when Resident #61 collapsed and was found cyanotic with fixed and dilated pupils and no pulse. The resident had been admitted to the facility and had the capacity to make his own medical decisions. He completed a Virginia Physician's Orders for Scope of Treatment (POST) form indicating he did not want CPR if he had no pulse and was not breathing, and the medical record also reflected a DNR order. A nursing note documented that CPR was initiated after the resident was found on the floor without a pulse, and 911 was called. When EMS arrived, the resident's code status was verified as DNR and life-saving measures were discontinued; the resident was pronounced dead by EMS. The Administrator stated the issue was discussed in an ad hoc QAPI meeting, and the root cause identified was an inexperienced nurse who had the incorrect electronic health record open when checking the resident's code status.
Failure to Provide Hand Hygiene Before Meal Service
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to resident hand sanitation before meals. During lunch tray pass, Nurse Aide #65 delivered trays to Resident #53 and Resident #6, who share the same room, and set up both trays without first offering hand sanitation to either resident. The nurse aide then left the room and returned to the hallway. When interviewed shortly afterward, she initially responded, "Um ., um," then retrieved hand wipes from the cart, returned to the room, and asked the residents if they had eaten yet and whether they would like to wipe their hands. The facility policy on Standard Precautions states that hand hygiene is to be performed before eating and before feeding or assisting in dining room tray pass.
Failure to Maintain Infection Control in Dining and Resident Room Areas
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two separate incidents. In the first instance, dirty dishes containing old food and drinks, including tea, milk, macaroni and cheese, and bread, were left in the dining room after the evening meal, with a resident's meal ticket found under the dinner plate. Additionally, a styrofoam cup without identification was observed on the dining room table. In the second instance, an oxygen cannula and tubing, along with a used bath basin, were found on the floor in a resident's room. The resident was noted to be confused and unable to answer questions regarding the items found on the floor. These observations were made during early morning hours and were confirmed by staff interviews.
Failure to Ensure Resident Dignity and Privacy During ADL Care
Penalty
Summary
A deficiency was identified when a resident was observed sitting in a wheelchair in front of a bathroom, wearing only a brief and no shirt, while the door to the hallway was open. During this time, a nurse aide was emptying the resident's urinary catheter bag and preparing to assist the resident further. The resident confirmed that the nurse aide was providing catheter care and preparing to assist with toileting. The Director of Nursing later confirmed that the door to the hallway should have been closed during this care activity. This incident demonstrated a failure to ensure the resident's dignity and privacy during activities of daily living (ADL) care.
Failure to Complete Discharge Planning and Permit Return After Acute Care Transfer
Penalty
Summary
The facility failed to complete discharge planning and did not permit a resident to return after an acute care transfer. The resident, who was cognitively intact and had capacity for medical decisions, had a complex medical history including peripheral vascular disease, COPD, congestive heart failure, dementia with behavioral disturbances, and other chronic conditions. The resident had a documented history of inappropriate sexual behaviors and other physical and verbal behaviors toward staff and other residents. On the date of the incident, the resident was sent to an acute care facility following another episode of inappropriate sexual behavior. Despite being medically and psychiatrically cleared at the acute care facility, the resident was not allowed to return to the facility. There was no active discharge planning in place, and the facility had only made referrals to other facilities several months prior, with no further follow-up. Interviews with the DON and Administrator confirmed that the decision was made not to allow the resident to return, and that no additional discharge planning or supervision measures were implemented at that time.
Inaccurate Medical Record Documentation for Resident Transfers
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident, as evidenced by incorrect dates documented on transfer forms related to the resident's multiple transfers to an acute care facility. During a record review, it was found that the dates on two separate transfer forms did not match the actual dates of transfer, with one form listing 02/02/23 instead of 03/26/24, and another listing 03/26/24 instead of 08/09/24. The Director of Nursing confirmed the errors and attributed them to nurses sometimes being in a hurry and not reviewing the transfer form dates.
Hallway Obstructions Limit Resident Access
Penalty
Summary
During an early morning tour of the facility, surveyors observed that hallways were obstructed by various items, including wheelchairs, geri chairs, mechanical lifts, a large portable air conditioning unit, and a linen cart. These items were parked along both sides of the hallway, blocking a direct path for movement up or down the corridor. A staff member, specifically an LPN, confirmed that the hallway did not provide a clear and direct path for residents to easily pass through. The facility census at the time was 57 residents. This situation was identified as a random opportunity for discovery and had the potential to affect a minimal number of residents.
Failure in Antibiotic Stewardship Leads to Resident Harm
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in harm to a resident. The resident had a urine culture that identified the bacteria as resistant to Nitrofurantoin (Macrobid). Despite this, the attending physician ordered Macrobid to treat the urinary tract infection (UTI). The resident received the full course of Macrobid, but her symptoms did not improve. Upon the family's request for a dose increase, the facility reviewed the culture again and discovered the error. The antibiotic was then changed to Bactrim, to which the bacteria was susceptible. The resident was later hospitalized with sepsis, metabolic encephalopathy secondary to UTI, acute kidney injury, and acute urinary retention. The facility's Antibiotic Stewardship Plan Policy and Procedure was not followed, as the Infection Preventionist did not verify the physician's order against the culture results. The Director of Nursing acknowledged that the physician misread the culture, and the Infection Preventionist did not follow her usual process of verifying and communicating the culture results. This oversight led to the resident receiving an ineffective antibiotic, contributing to her hospitalization.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring the lid on the dumpster was closed. During an observation conducted on August 21, 2024, at 1:40 PM, with the Nursing Home Administrator (NHA) present, it was found that the lid of the facility's dumpster was open. Upon inspection, a bag of trash was noted inside the dumpster. The NHA confirmed that the dumpster lid should have been closed. This deficiency was identified during the facility task of inspecting the kitchen and has the potential to affect all 56 residents currently residing in the facility.
Unsafe Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure safe food handling practices during the preparation of a thickened drink for a resident. During an observation in the dining room at breakfast time, a Certified Nursing Assistant (CNA) was seen mixing a thickened juice drink while holding the glass with her bare hand. Specifically, the CNA placed her pointer finger and thumb on the top rim of the glass as she stirred the liquid with the opposite hand. When questioned, the CNA confirmed that the resident would be drinking from the rim of the glass and acknowledged the need to re-mix another drink. The Clinical Manager Registered Nurse (CM RN) was informed of the incident and expressed that the CNA should have known better, subsequently disposing of the drink.
Failure to Obtain MPOA Signature for Advance Directive
Penalty
Summary
The facility failed to properly formulate an advance directive for a resident by not obtaining the necessary signature from the Medical Power of Attorney (MPOA). During a medical record review, it was found that the facility had only obtained a verbal confirmation of agreement from the resident's MPOA on 06/09/22, but had not secured the required signature. This deficiency was identified during a review of the West Virginia Physician Order for Scope of Treatment (WV POST) form for the resident. According to the guidance for health care professionals, verbal confirmation can be obtained, but the form should be signed at the earliest available opportunity. The Assistant Director of Nursing confirmed during an interview that the signature had not been obtained as required.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for two residents during the long-term care survey process. For Resident #21, an observation on 08/19/24 at 9:23 AM revealed that the face of the drawer in the bottom of the wardrobe was missing. This deficiency was confirmed with the Registered Nurse Unit Manager #76 at 9:45 AM on the same day. For Resident #112, an observation on 08/19/24 at 9:23 AM found that there were three curtain hooks missing from the privacy curtain between the entrance door and the bed, causing the curtain to hang down on one corner. This issue was also confirmed with the Registered Nurse Unit Manager #76 at 9:45 AM.
Failure to Implement Abuse Prevention Measures
Penalty
Summary
The facility failed to implement and ensure actions were in place to prevent further potential abuse, as identified during a long-term care survey. The deficiency involved an incident where a resident allegedly attempted to inappropriately move the hand of another resident to their groin area. Staff witnesses confirmed the allegation, and the facility initially placed the resident on one-on-one supervision. However, the attending physician, who was present at the time, stated that the resident did not need such supervision, and the physician's order for one-on-one supervision was not entered until the following day. The Director of Nursing (DON) believed that the one-on-one supervision had continued, but was unable to provide documentation to support this belief. As a result, the residents, including the victim of the incident, were not provided protection from further potential abuse from the time the staff became aware of the initial incident until the supervision was officially started the next day. This lapse in supervision and protection measures constituted a deficiency in the facility's policy and procedure for abuse prevention.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident abuse involving a resident identified as Resident #3 and another unidentified resident. This incident occurred when Resident #3 was observed throwing a cup of water in the face of another resident. Upon reviewing the facility's incidents and reportables logs, it was found that this incident was not documented. Additionally, the facility's Administrator confirmed that the incident was neither reported nor investigated. Resident #3's care plan included a note under the focus area for behaviors, indicating a history of throwing water at staff and residents.
Inaccurate MDS Assessment Upon Resident Discharge
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Assessment for a resident upon discharge. During a record review, it was discovered that the discharge location for the resident was incorrectly entered as a Short-Term General Hospital instead of Home/Community. This error was identified in the section of the MDS completed and signed by the Social Worker (SW). The SW acknowledged the mistake during an interview, attributing it to a typographical error, possibly due to confusion with the resident's previous location before admission to the facility.
Failure to Update PASARR for Residents with New Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) for two residents following new diagnoses of major depressive disorder. For Resident #34, the PASARR was initially completed on 11/25/22, but was not updated after the resident was diagnosed with major depressive disorder on 03/20/24. During an interview, the social worker acknowledged that the PASARR should have been updated at the time of the new diagnosis. Similarly, for Resident #39, who was admitted to the facility and diagnosed with major depressive disorder on 08/09/23, the PASARR was not updated to reflect this new diagnosis. The social worker confirmed responsibility for submitting PASARRs and admitted that a new PASARR had not been completed for Resident #39 following the diagnosis, stating that they were working on updating the necessary PASARRs.
Incomplete PASARR Form for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) form included all appropriate diagnoses for a resident. During the survey process, it was found that the PASARR form for one of the three residents reviewed only listed dementia as a diagnosis. However, upon admission, the resident also had diagnoses of bipolar disorder, depression, and generalized anxiety disorder. This discrepancy was confirmed by Social Worker #77, who acknowledged that all the diagnoses should have been included on the PASARR form.
Failure to Develop Comprehensive Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an ileostomy, specifically regarding diet restrictions. During a noon meal observation, the resident was served corn, which she immediately identified as something she could not eat due to her medical condition. Her family member confirmed that the facility frequently served her inappropriate foods. A review of the resident's tray ticket indicated she was supposed to receive an alternate vegetable, and her care plan lacked any mention of diet restrictions related to her ileostomy. Interviews with the Registered Dietician and the Director of Nursing confirmed the oversight, acknowledging that corn could cause a blockage for the resident.
Failure to Revise Care Plans for Medication and Diagnosis Changes
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents in a timely manner, as required by regulations. Resident #34 was diagnosed with major depressive disorder on 03/20/24, but the care plan was not updated to reflect this diagnosis. This oversight was confirmed during an interview with the Director of Nursing (DON) on 08/21/24. Resident #14's care plan included the use of Seroquel for schizophrenia, agitation, and abrasive language, but the medication was discontinued on 04/02/24 without an update to the care plan. Additionally, Resident #14 was receiving Melatonin for insomnia, which was discontinued on 04/23/24, yet the care plan was not revised. Similarly, Resident #24's care plan listed Zoloft for depression, but the medication was discontinued on 05/31/24 without a corresponding update to the care plan. These deficiencies were confirmed with the DON on 08/20/24.
Failure to Act on Physician's Order for Stool Testing
Penalty
Summary
The facility failed to act on a physician's order for a resident, leading to a delay in treatment. The resident had an active order dated 07/26/24 to perform hemoccult stool tests for three samples due to an abnormal lab result. However, as of 08/20/24, only one stool sample had been obtained, which was collected on 08/17/24 and returned positive for blood. Despite receiving new orders to continue monitoring and follow up with the in-house physician for a possible GI referral, there was no documentation indicating that the in-house physician had been notified, and no further stool samples were collected after 08/17/24. The Director of Nursing acknowledged that it took 21 days to obtain the stool sample and 24 days since the original order was placed without further action.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of all residents, as evidenced by an incident involving two residents. Resident #44 reported that their call light was not answered for approximately 40 minutes during the early morning hours. The delay was attributed to the reassignment of their assigned aide to provide one-on-one care for another resident, Resident #34. This reassignment left only two staff members to cover the entire nursing home, resulting in Resident #44's needs not being promptly addressed. The Director of Nursing (DON) confirmed that the aide originally assigned to Resident #44 was reassigned to provide one-on-one care for Resident #34, but there was no documentation of the new staff assignments. The incident was reported to the Administrator, and an investigation was initiated. A statement from another nurse aide indicated that Resident #44's call light was answered after the aide arrived for their shift, and the resident was found to be wet, indicating a lack of timely care. The facility's failure to document staff reassignments contributed to the deficiency in care.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor a resident for side effects of antianxiety, antidepressant, and mood-stabilizing medications as ordered. The resident had specific orders for monitoring side effects such as dystonia, anticholinergic symptoms, hypotension, sedation, cardiac abnormalities, and other symptoms every shift. Additionally, the resident was to be monitored for behaviors like hallucinations, delusions, and violent outbursts, with non-pharmacological interventions such as snacks, fluids, activities, and distractions to be used every shift. However, the record review revealed that behavior monitoring was absent from the Medication Administration Record (MAR) on multiple days and shifts across several months. The report also highlighted missing side effect monitoring for the resident's antianxiety, antidepressant, and mood stabilizer medications on various days and shifts. This lack of monitoring was acknowledged by the Director of Nursing (DON) during the survey process. The facility's failure to consistently monitor the resident as ordered represents a deficiency in adhering to prescribed care protocols, potentially impacting the resident's health and safety.
Medication Error Due to Nurse's Inexperience
Penalty
Summary
The facility failed to ensure that significant medication errors did not occur, as evidenced by an incident involving a resident who received incorrect medications. On a specific date, a resident was administered medications that were not prescribed to them, including Lipitor, Isosorbide Dinitrate, Doxepin HCL, Melatonin, Propranolol HCL, Buspirone, PreserVision AREDs, and Klonopin. This error occurred because the nurse, who was new and unfamiliar with the residents, mistakenly gave the resident their roommate's medications. The resident's prescribed medications included Atorvastatin, Buspirone, Colestid, Dicyclomine, Empagliflozin, Loratadine, Losartan Potassium, Magnesium Oxide, Metformin, Metoprolol Succinate ER, Omeprazole, Remeron, Sertraline, Tylenol, and Zenpap DR. The error was identified, and the physician was notified, leading to a new order to hold the resident's nighttime medications except for Sertraline and to monitor for adverse reactions. The resident's Medical Power of Attorney was also informed, and neurological checks were initiated. The facility's policy and procedure for medication administration emphasize observing the five rights of medication administration, which include the right resident, time, medicine, dose, and route. However, a review of in-service training records showed that only eight out of twenty-five nursing staff had signed off on being educated about these five rights, and the nurse responsible for the error had not received this education.
Failure to Provide Appropriate Diet for Resident with Ileostomy
Penalty
Summary
The facility failed to provide a resident with a diet that met her special dietary needs related to her ileostomy. During a noon meal observation, the resident was served corn, which she immediately identified as something she could not eat due to her ileostomy. Her family member, upon entering the dining room, assisted in removing the corn from her plate and expressed that the facility frequently served her inappropriate foods. A review of the resident's tray ticket indicated she was supposed to receive a squash medley instead of corn, but this was not followed. Further investigation revealed that the resident's care plan lacked any special diet restrictions related to her ileostomy. The Registered Dietician confirmed that corn should be avoided as it could cause a blockage, and it was noted in the tray tracker system to serve squash medley instead. The certified dietary manager admitted to missing the correct vegetable on the tray ticket, resulting in the resident being served the wrong food.
Documentation Errors in Resident Discharge and Capacity Assessment
Penalty
Summary
The facility failed to accurately document the discharge of a resident and complete a resident's capacity form, leading to deficiencies identified during the survey process. For Resident #59, the medical record review revealed that the discharge was not properly documented. The resident went on a therapeutic leave with his daughter, who later informed the facility that he would not be returning. However, there was no physician note entry for the discharge to family, and the Minimum Data Set (MDS) indicated the discharge was unplanned. The Director of Nursing (DON) confirmed that the resident was discharged against medical advice (AMA), but the facility's census list inaccurately coded the discharge, which the Administrator acknowledged. For Resident #35, the Physician's Determination of Capacity form was incomplete. Although the form was signed by the physician and indicated long-term duration, short-term memory loss, aphasia, inability to process information, and CVA as causes, it failed to specify whether the resident demonstrated capacity or incapacity to make decisions. The Unit Manager RN (UMRN) acknowledged the form was not completed correctly, suggesting the resident likely did not have capacity. These documentation errors highlight the facility's failure to maintain accurate medical records in accordance with professional standards.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents entering into a binding arbitration agreement were able to understand the agreement prior to signing. This deficiency was identified during a survey process where two residents were reviewed for arbitration agreements. One resident, upon interview, stated that they did not recall signing the arbitration agreement and mentioned that they were handed multiple documents to sign upon admission without clear explanation. This indicates a lack of proper communication and understanding regarding the arbitration agreement. Additionally, another resident who was deemed incapacitated signed the arbitration agreement while still incapacitated. The facility's social worker, responsible for handling arbitration agreements, admitted to not reviewing the capacity form before having the resident sign the agreement. The social worker assumed the resident had capacity due to the absence of a capacity form, highlighting a procedural oversight in verifying the resident's ability to consent to the agreement.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews and observations during the survey process. Residents reported long wait times for assistance, inconsistent water delivery, and missed showers due to staffing shortages. One resident mentioned waiting almost an hour for a call light to be answered, while another noted that meal trays were left uncollected, cluttering their space. The facility's task sheet confirmed that a resident did not receive a scheduled shower, and the unit manager acknowledged that the documentation was improperly marked. During a resident council meeting, several residents expressed concerns about the inconsistency of water delivery and the lack of staff presence, particularly during night shifts. Observations during a night shift tour revealed that call lights were left unanswered while staff were found sitting and talking in the activity room. When approached by a surveyor, the staff members promptly began addressing the call lights, indicating a lapse in their duties prior to the surveyor's intervention. Staff interviews and record reviews further highlighted the staffing issues, with a registered nurse acknowledging the shortage of CNAs. The facility's daily punch audits showed that the number of nurse aides on duty often fell below the facility's identified requirement of five aides per shift. This staffing inadequacy was consistent across multiple days, contributing to the residents' unmet needs and the overall deficiency in care.
Inconsistent Water Delivery to Residents
Penalty
Summary
The facility failed to ensure proper hydration for its residents, as evidenced by the inconsistent delivery of water to Resident #52 and other residents. During an interview, Resident #52 expressed concerns about the lack of staff and the inconsistency in water delivery, stating that she did not receive water the previous night despite repeated requests. Observations confirmed that no water was delivered to Resident #52's room during the surveyor's presence, and the Unit Manager and Nurse Aide acknowledged the oversight. The absence of a water pitcher in Resident #52's room further highlighted the deficiency. Additionally, during a resident council meeting, multiple residents, including Residents #7, #32, #36, and #41, voiced similar concerns about the inconsistency in receiving water. They reported that water delivery was erratic, with some shifts providing water and others not, and sometimes not receiving water at all. These testimonies from the residents indicate a broader issue within the facility regarding the consistent provision of hydration, affecting more than just a limited number of residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents the spread of foodborne illnesses. During an observation of the noontime meal, a facility cook prepared chicken pot pie and recorded its temperature at 143 degrees Fahrenheit, which is below the required 165 degrees Fahrenheit. Despite being informed of the inadequate temperature, the food was served to residents. A review of service line checklists revealed multiple instances where food items were not cooked to the appropriate temperature, including pureed rancher chicken, jambalaya, turkey, hot dogs, and pureed hot dogs. The facility's kitchen was found to be in an unsanitary condition with numerous items improperly labeled or stored past their expiration dates. During an initial tour of the kitchen, several items in the reach-in refrigerator, walk-in cooler, and dry storage were either not labeled or had expired, including bowls of cake, applesauce, pudding, salad, and various juices. The kitchen's cleanliness was also compromised, with food particles in the microwave, debris on the steam table shelves, and baked-on food on cooking equipment. The state agency identified these failures as placing all 55 residents in immediate jeopardy due to the potential for serious harm or death from foodborne illnesses. The facility was notified of the immediate jeopardy situation, which began when the state agency first identified the failure to cook food to the appropriate temperature. The deficient practices had the potential to affect all residents as they all receive meals from the facility's kitchen.
Removal Plan
- An assessment was conducted with all residents currently residing within the center by director of nursing/designee to determine if any residents reported or exhibiting signs and/symptoms that could be related to food borne illness resulting in no concerns reported.
- All center residents will be monitored each shift for new onset food borne illness symptoms.
- The center administrator/designee provided all available dietary staff education on the Food Preparation Policies, which includes the requirement to take appropriate temperatures and record them on the Service Line Checklist to ensure food is prepared and held at a safe temperature to prevent the spread of food borne illness prior to serving food from the service line with post-test to validate understanding. All dietary staff not available for education and training will be re-educated upon return to work.
- An ongoing audit will be conducted by the interim food services manager/designee, for each meal and randomly thereafter to ensure appropriate temperatures as determined by food service production logs, are obtained, and recorded on the Service Line Checklists prior to the service of meal. Food outside of required temperatures will not be served. Audits will be reviewed weekly with the ED or designee and submitted for review to the Quality Assurance Committee and then when random audits are completed.
Failure to Secure Janitor's Closet with Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible by not keeping the janitor's closet door in the dining room locked. Observations on two consecutive days revealed that the door, which had an electronic locking keypad, could be easily pushed open. This was confirmed by the Maintenance Director, who noted that items hanging on the door sometimes prevented it from latching properly. After removing the items, the door latched and remained locked. Inside the janitor's closet, there were several hazardous chemicals, including a Rapid Multi Surface Disinfectant cleaner, a Dual Action floor cleaner, and a Bio-Enzymatic Odor Eliminator. The Safety Data Sheets for these chemicals indicated that they posed significant risks, such as causing severe skin burns and eye damage, and required storage in a locked location. The failure to secure the closet door exposed residents to potential harm from these chemicals.
Incomplete Investigation of Resident Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of physical abuse between two residents. Resident #42 entered the room of Resident #52 during the night shift and, after a verbal altercation, struck Resident #52 in the head multiple times. The facility's investigation included statements from three staff members, but none were from the night shift staff who were present during the incident. The statements indicated that Resident #52 used his call light to summon help, suggesting that night shift staff were aware of the situation, yet no statements were obtained from them. During an interview, the Director of Nursing, Social Worker, and Nursing Home Administrator acknowledged that statements should have been collected from the night shift staff to ensure a thorough investigation. The Social Worker noted that the incident was only reported during the day shift when Resident #52 mentioned it to a CNA. Despite the clear indication that night shift staff responded to the call light and separated the residents, the facility did not obtain their accounts, leading to an incomplete investigation of the abuse allegation.
Failure to Conduct Neurological Assessments After Resident Altercation
Penalty
Summary
The facility failed to provide necessary neurological assessments for a resident following an incident where another resident reportedly hit him in the head multiple times. The incident occurred when the resident was asleep in his room, and another resident entered, became agitated, and began throwing items and hitting the resident in the head. Despite the reportable incident being documented, a review of the resident's medical record showed no neurological assessments were conducted post-incident. An interview with the Director of Nursing confirmed the absence of these assessments, which were required according to the facility's policy on neurological checks for incidents involving blows to the head.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ansted Center | 5.2 mi | ★★★★★ | 19 | 0 |
| Hidden Valley Center | 5.3 mi | ★★★★★ | 9 | 0 |
| Hilltop Center | 9.4 mi | ★★★★★ | 15 | 0 |
| Montgomery General Hospital | 15 mi | ★★★★★ | 0 | 0 |
| Montgomery General Elderly Care | 15 mi | ★★★★★ | 14 | 0 |
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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.