Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Keyser Healthcare Center during CMS and state inspections, most recent first.
Unsafe water temperatures were found in resident rooms, a shower room, and a dining room sink, with readings as high as 127 degrees F and a whirlpool bath used for resident bathing despite a faulty temp gauge. An MDS stated the mixing valve serving the 100 and 200 halls had been installed backwards and was difficult to read and adjust, while staff reported frequent hot water issues and having to check water by hand. The facility also failed to implement appropriate safety precautions for residents at risk of falls.
Surveyors found that multiple residents did not receive medications, wound care, or blood glucose monitoring as ordered by their physicians. Several residents reported late or missed medications, and record reviews confirmed repeated delays in administration. Wound care treatments for a resident with venous ulcers were not completed as prescribed, and several residents with diabetes did not receive accuchecks as ordered. These deficiencies were confirmed by facility leadership.
Failure to Honor Resident Bath and Shower Preferences: Three residents were not given baths or showers according to their stated preferences or scheduled bath days. One resident requested a whirlpool bath and the CNA did not return, another reported no bath or shower for an extended period, and a third was marked as not attempted for medical or safety reasons without supporting clinical documentation. The DON/Administrator confirmed the residents' preferences were not honored and that documentation was inaccurate.
Medication storage and labeling were not maintained as required. In one med room, refrigerator temp logs for meds, insulin, and vaccines were missing on multiple days, and in another med room the med refrigerator log was also incomplete. An LPN found an Ozempic injector for a resident stored in the refrigerator even though the box showed it had been opened months earlier; the pen should have been discarded per the manufacturer’s 56-day use limit.
Food was not consistently served at a palatable or appetizing temperature. Two residents reported that meals were not hot or were horrible, and one resident said she had gone without food because she disliked the taste of what was served. Tray checks found hot items such as sweet potatoes, broccoli, and ham at low temperatures, while iced tea was served cold. The facility’s policy stated food should be palatable, attractive, and served at a safe and appetizing temperature.
The facility failed to keep accurate and complete resident records. One resident had conflicting capacity documentation and a missing POST form in the EMR despite DNR status, while other records included a transfer form with blank vital signs and the wrong date, a progress note listing an incorrect HIV diagnosis, another transfer form with an incorrect date, and a psychotropic med eval with the targeted psychiatric or behavioral symptoms left blank.
The facility failed to maintain infection control practices when housekeeping staff and an NA entered contact precaution rooms without PPE, stating they did not think PPE was needed if the resident or roommate was out of the room. Additional concerns were noted when a fracture pan, bath basin, and a nebulizer mask were found stored improperly without identification or appropriate storage bags.
The facility failed to post a notice of survey results availability and did not keep the survey results binder in an accessible, visible location for residents and visitors. Residents in council could not say where the binder was, staff could not readily locate it, and it was found behind the receptionist desk and later covered with COVID supplies in the lobby.
A resident’s PASRR form did not include her current diagnosis at admission. The PASRR listed no current diagnosis, while the resident’s record showed Bipolar Disorder, Unspecified. The Administrator stated a new PASRR had been completed and was awaiting the physician’s signature.
Incomplete care plans and unimplemented interventions were identified for two residents. One resident with PTSD had reported specific triggers, including certain sounds and smells, but the care plan did not list any PTSD triggers, and the DON and Administrator acknowledged this omission. Another resident was documented as dependent for personal hygiene but went multiple stretches without a shower or bed bath, and a fall intervention calling for a mat beside the bed was not in place when observed; an NA confirmed the mat was missing.
Failure to provide bathing assistance to a dependent resident. Record review showed a resident did not receive showers or bed baths during multiple extended periods, and the Administrator confirmed that ADLs were not provided as required.
A resident who was incontinent reported waiting too long for toileting help and often sitting in wet briefs, while records showed multiple missed or delayed toileting checks despite an expectation for q2h toileting. Another resident with nephrostomy tubes reported that nursing staff did not flush the tubes as ordered three times daily and that she often had to remind staff to provide the care. The record also showed the grievance about missed nephrostomy care was not documented as investigated or resolved.
The facility failed to ensure monthly pharmacy reviews were signed, dated, or had physician responses for two residents. One resident’s review noted a need for a Valproic Acid level while another resident’s review flagged concurrent Clonazepam and Oxycodone use with a black box warning. The Regional Director and DON stated the signed copies were not available.
Unsafe Water Temperatures and Inadequate Fall Precautions
Penalty
Summary
The facility failed to ensure safe water temperatures in resident-accessible areas, including a resident room, the South Shower Room, the main dining room sink, and the North shower room sink. On 11/18/25, water in a resident room was measured at 119.8 degrees Fahrenheit and then 124.6 degrees Fahrenheit. In the main dining room, the hand-washing sink was too hot to touch and measured 127 degrees Fahrenheit. In the North shower room, the sink water was measured at 121 degrees Fahrenheit. During inspection of the South shower room, a whirlpool bath was observed in use for resident bathing. A nurse aide stated she usually gave residents baths, adjusted the water based on the resident’s request, and checked the water temperature with her hand because the gauge on the whirlpool bath was faulty. She also stated that the knob controlling the water had to be turned counterclockwise to adjust from hot to cold and that she frequently had to tell other nurse aides not to set the temperature too high. Another nurse aide stated that water temperatures in the 200 hallway were very hot the day before the inspection. The Maintenance Director stated that the facility’s hot water was supplied by three hot water heaters and that the mixing valve serving the 100 and 200 hallways had been installed backwards. He stated that the valve was difficult to read and adjust and that he had difficulty obtaining an accurate reading. Inspection showed the valve readout facing the wall behind the water heater, with the setting in the red zone between 110 and 120 degrees Fahrenheit. A resident with a BIMS score of 15 stated that maintenance staff frequently adjusted the water temperatures. The report also states that the facility failed to implement appropriate safety precautions for residents at risk of falls.
Failure to Follow Physician Orders for Medications, Wound Care, and Accuchecks
Penalty
Summary
Surveyors identified that the facility failed to follow physician's orders and provide appropriate treatment and care according to orders, resident preferences, and goals for multiple residents. Specifically, several residents did not receive their medications at the prescribed times, with documented instances of medications being administered hours after the scheduled times. Residents reported that their medications were sometimes late or, in some cases, not given at all. Review of medication administration records over a 30-day period confirmed repeated late administration of critical medications, including anticoagulants, antihypertensives, and psychotropic drugs. In addition to medication administration issues, the facility did not complete ordered wound care treatments for a resident with multiple venous ulcers and moisture-associated skin damage. The prescribed wound care regimen, which included cleansing, application of topical medications, and specific dressing changes, was not performed as ordered on a documented date. The administrator confirmed that these treatments were missed. The facility also failed to perform blood glucose monitoring (accuchecks) as ordered for several residents with diabetes. Multiple instances were found where daily, twice daily, or scheduled accuchecks were not completed according to physician orders. The DON confirmed that these orders were not followed, and the missed accuchecks were verified through record review.
Failure to Honor Resident Bath and Shower Preferences
Penalty
Summary
The facility failed to honor resident choices for baths and showers for three residents. Resident #71 stated that on her bath day she was asked whether she wanted a bed bath or a tub bath, requested a whirlpool bath, and said the nurse aide left her room and did not return. The resident reported that her last tub bath had been on 10/30/25 and that she filed a grievance about not receiving the bath she requested. The grievance form documented that the resident asked for a whirlpool bath and that the CNA did not come back to bathe her, with the task sheet marked not applicable. Resident #73 stated that she had not received a shower or bath since 10/21/25, and her grievance stated that she had not been offered a bath or shower since that date. Resident #95 stated that she did not receive a bath on her scheduled bath day, and her grievance documented that she was not offered a bath on her scheduled day while the task sheet was checked as activity not attempted due to medical conditions or safety concerns. Record review found no physician or nursing notes documenting any medical or safety concerns for Resident #95. The Administrator confirmed that the residents' preferences had not been honored and that staff failed to thoroughly investigate and document the interventions accurately.
Medication Storage and Expired Opened Medication Handling
Penalty
Summary
The facility failed to ensure that opened medications were discarded within the manufacturer-specified period and failed to ensure that medications were stored at the manufacturer-specified temperatures. In the 100/200 hallway medication room, three locked refrigerators were observed for medications, insulin, and vaccines, but the refrigerator temperature logs were not available in the room. When the logs were reviewed, the medication refrigerator log was not completed for the day shift on 11/13/25, 11/17/25, 11/18/25, 11/19/25, and 11/20/25; the insulin refrigerator log was not completed for the day shift on 11/12/25, 11/17/25, 11/18/25, 11/19/25, and 11/20/25; and the vaccine refrigerator log was not completed on 11/17/25, 11/18/25, 11/19/25, and 11/20/25. In the 300/400 hallway medication room, three refrigerators were observed for medication, vaccines, and insulin, with temperatures reading 41, 42, and 42 degrees Fahrenheit. The vaccine and insulin refrigerator logs were completed, but the medication refrigerator log was not documented on 11/17/25 and 11/20/25. During this inspection, an Ozempic injector for Resident #11 was found stored in the medication refrigerator with a label stating it had been opened on 06/25/25. An LPN confirmed the pen should have been discarded and removed it from the refrigerator. Review of Resident #11's medications showed an Ozempic pen dated 11/03/25 that was currently in use, and the manufacturer’s guidance stated the pen may be used for up to 56 days after first use and must be discarded after 56 days even if medication remains.
Food Not Served at Palatable or Appetizing Temperatures
Penalty
Summary
Food and drink were not provided at a palatable, attractive, and safe appetizing temperature for residents. During an interview, Resident #35 reported that his food was not good and was not hot when served. Resident #107 reported that the food was horrible, that out-of-menu items were often unavailable when she did not like the meals served, and that she had gone without food because she disliked the taste of everything served. During tray temperature testing, the last tray removed from the cart showed candied sweet potatoes at 100 degrees Fahrenheit, broccoli florets at 114 degrees Fahrenheit, honey glazed sliced ham at 104 degrees Fahrenheit, and iced tea at 36 degrees Fahrenheit. The facility's Food: Quality and Palatability document stated that food would be prepared to conserve nutritive value and appearance and would be palatable, attractive, and served at a safe and appetizing temperature.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents reviewed during the survey. For one resident, the record contained a physician determination of capacity stating the resident had capacity to make medical decisions, even though the MDS showed a BIMS score of 0 indicating severe cognitive impairment; the Administrator stated the capacity form was incorrect and that a new physician form later stated the resident demonstrated incapacity. The same resident’s EMR also noted DNR status, but the POST form was not scanned into the EMR and was not readily available when the DNR notation was entered. For another resident, the transfer form for an acute care transfer left the vital signs blank and listed the wrong transfer date. A progress note for a different resident listed HIV as a diagnosis even though HIV was not included in the resident’s diagnoses, and the Administrator later confirmed the diagnosis was incorrect after a physician addendum identified the note as a dictation error. A transfer form for another resident also listed an incorrect date, and a psychotropic medication evaluation for a fourth resident did not identify the targeted psychiatric or behavioral symptoms because section 3 was left blank.
Infection Control Lapses With PPE and Improper Equipment Storage
Penalty
Summary
The facility failed to maintain an infection control program during housekeeping services in room #103 and during ADL care in room #115, both of which were under contact precautions. On 11/17/25, Housekeeping #289 was observed in room #103 without PPE and stated, "I thought if they were out of the room, I didn't have to wear it." The Administrator later confirmed PPE should be worn in a room under contact precautions. On 11/18/25, Nurse Aide #50 was observed providing ADL care to Resident #66 in room #115 without PPE and stated, "I didn't think I had to wear it, if her roommate was out of the room." Resident #66's roommate was noted to have draining wounds, and the Administrator confirmed PPE should be worn in a room under contact precautions. Additional infection control concerns were observed in room #103 and for Resident #75. In room #103, a fracture pan and bath basin were found on a shelf under the sink without identifying information and without a storage bag in place; Nurse Aide #42 stated they did not know whether the items were used and would get rid of them. For Resident #75, a nebulizer mask was observed laying on the nightstand, and Nurse Aide #102 stated they would get a storage bag. The Administrator confirmed the fracture pan, bath basin, and nebulizer mask should be stored in appropriate storage bags.
Survey Results Binder Not Accessible or Visible
Penalty
Summary
The facility failed to post a notification of the availability of survey results and failed to provide the survey results in an accessible location for review by residents and visitors. During the Resident Council meeting, none of the 14 residents attending could verbalize where the survey results binder was located. A surveyor then attempted to find the binder without success, and a Social Services designee stated they did not know where it was and needed to ask someone else. The survey results binder was later obtained from behind the receptionist desk after the corporate RN asked the receptionist for it. The receptionist confirmed the binder was kept behind the desk due to wandering residents. On a later observation, the binder was not visible in the lobby and was found at the receptionist's desk covered with COVID supplies. When the Administrator was shown that the binder was not easily visible or accessible, the Administrator moved it to a small table visible to anyone entering the lobby.
PASRR Form Missing Current Diagnosis
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was deficient for one resident because the facility failed to ensure the resident’s PASRR form included her current diagnosis at the time of admission. A review of the resident’s PASRR dated 09/19/23 showed that question #30, Current Diagnosis, was marked “None,” while a diagnosis report reviewed on 11/18/25 listed Bipolar Disorder, Unspecified, with an onset date of 8/31/23. During an interview on 11/20/25, the Administrator stated that a new PASRR had been completed and was awaiting the physician’s signature for submission, and that the facility had started an audit to correct and update all PASRRs.
Incomplete Care Plans and Unimplemented Interventions
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents. Resident #8 had a diagnosis of Post-Traumatic Stress Disorder (PTSD), and during interviews she reported specific triggers related to sounds and smells associated with rain, leaves, wet ground, homecoming, and certain noises around fall. She also stated she did not like to leave her room because she felt unsafe and described losing trust in a physician who stopped coming after two visits. Review of the care plan on 11/20/25 showed no triggers listed under the PTSD care area, and the DON and Administrator acknowledged the care plan did not address the resident’s PTSD triggers. Resident #4 had a care plan intervention indicating the resident was dependent for personal hygiene and required two or more helpers, but record review showed the resident did not receive a shower or bed bath during multiple date ranges in September, October, and November 2025. In addition, Resident #4 had a fall with major injury, and the care plan included a fall mat on the right side of the bed as an intervention. On observation, the fall mat was not in place at the right side of the bed, and a nurse aide confirmed it was not in place. The Administrator later confirmed the fall mat should have been in place.
Failure to Provide Bathing Assistance to a Dependent Resident
Penalty
Summary
Facility staff failed to provide ADL assistance to a dependent resident, Resident #4, specifically related to bathing. Record review showed the resident did not receive a shower or bed bath during multiple periods: 09/01/25-09/12/25, 09/19/25-09/26/25, 10/10/25-10/21/25, and 10/31/25-11/04/25. The deficiency was identified during record review on 11/19/25, and on 11/20/25 the Administrator confirmed that ADLs were not provided to the dependent resident.
Missed Toileting Assistance and Nephrostomy Care
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bowel and bladder received timely toileting assistance. Resident #45 stated that she had to wait for help when she needed to use the bathroom and often ended up sitting in wet briefs for long periods of time. She also reported that she had submitted a complaint to the facility because staff did not get to her in time after she used her call light to request toileting assistance. Record review showed that Resident #45 had diagnoses including Syndrome of Inappropriate Secretion of Antidiuretic Hormone, Type 2 Diabetes Mellitus without complications, Hypertensive Heart Disease, and Muscle Weakness, and had the capacity to make her own decisions. The record and care plan review did not show orders or care plan updates addressing toileting frequency, although the facility stated the resident was to be toileted every 2 hours. The bladder tracker log showed multiple gaps in toileting checks, including intervals of several hours between documented checks on numerous dates. The facility also failed to ensure appropriate care for Resident #73’s nephrostomy tubes as ordered by the physician. The resident stated that nursing staff did not flush the nephrostomy catheters three times a day as ordered and that she frequently had to remind staff when it was time for care. She reported that she had filed a complaint about the missed care and that she was frustrated by having to monitor the schedule herself. The record showed orders for flushing bilateral nephrostomy tubes three times daily, checking for kinks or obstructions every shift, and assessing the exit site for signs of infection and skin breakdown, but the grievance record did not document an investigation or action to resolve the complaint about staff not following the physician’s orders.
Missing Physician Signatures and Responses on Monthly Pharmacy Reviews
Penalty
Summary
The facility failed to ensure that monthly pharmacy reviews were signed, dated, or included a response from the facility physician to the consultant pharmacist’s recommendations for two residents reviewed under the care area of unnecessary medications. For Resident #12, the monthly pharmacy review for 05/25/25 was not signed by the physician and no response was recorded. The pharmacist noted that the resident was prescribed Divalproex and was due for a Valproic Acid level ordered every six months, and asked that the level be obtained on the next convenient lab day. For Resident #5, the monthly pharmacy review dated 07/29/25 was not signed, dated, or accompanied by a physician response. The consultant pharmacist documented that the resident was receiving Clonazepam and Oxycodone and included a black box warning regarding the combined use of opiate agonists with benzodiazepines, stating that the resident’s concurrent use of these medications should be reassessed to ensure the benefits outweighed the risks. During interview, the Regional Director and DON stated they did not have the signed copy of the pharmacy review or recommendation response.
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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 Keyser
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Moran Nursing And Rehabilitation Center | 5.7 mi | ★★★★★ | 4 | 0 |
| Egle Nursing Home | 9.3 mi | ★★★★★ | 31 | 0 |
| Complete Care At Dawnview Llc | 12.9 mi | ★★★★★ | 11 | 0 |
| Frostburg Rehab Center | 15.6 mi | ★★★★★ | 54 | 0 |
| Mountain City Rehab Center | 16.3 mi | ★★★★★ | 33 | 0 |
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