Above 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 Majestic Care Of Beckley during CMS and state inspections, most recent first.
The facility failed to carry out the comprehensive care plan for multiple residents. A resident with diabetes had an insulin order to hold Basaglar when BG was below 80 mg/dL, but the care plan did not include that parameter and the insulin was still given when BG was 77 mg/dL. Another resident's care plan required Dycem on the recliner, but it was not present when observed and was confirmed missing by nursing staff.
A resident was not served lunch at the same time as other residents seated at the same table, with meals being delivered to others first on two observed occasions. Surveyors observed the resident waiting while another resident or residents at the table were served earlier, and the timing was confirmed by an RN and the DON.
PASRR screening was incomplete for two residents because the facility did not ensure the PAS reflected all pre-admission diagnoses. One resident’s PASRR omitted schizophrenia and epilepsy, and another resident’s PASARR did not capture seizure disorder, even though both residents had those diagnoses documented in their records and related meds/care plan focus areas were present.
Failure to follow physician orders affected two residents. One resident’s ordered lunch tray items, including two peanut butter and jelly sandwiches, were missing on two observations despite the dietary order, and an RN later retrieved the sandwiches after checking the order. Another resident received Basaglar insulin even though the BG reading was below the ordered hold parameter, and the ADON confirmed the medication was given outside the physician’s instructions.
Failure to maintain or improve ROM and mobility was identified for a resident with foot and ankle contractures. Record review and staff interview showed the resident was never screened or evaluated by PT, and the restorative exercise log only documented UE AAROM, wheelchair push-ups, and LE sitting exercises that did not address the ankle contractures. The care plan noted therapy would screen, evaluate, and treat the resident per physician orders, but therapy had not done so.
A resident did not have dycem in the recliner as identified in the care plan to help prevent falls. During an observation, an RN confirmed the recliner was missing the dycem.
Failure to Provide Ordered Slow-Sip Cup: A resident with a history of swallowing and choking problems, edentulous status, and a mechanically altered diet was observed in the dining room with milk cartons and straws but no slow-sip cup, even though the cup was listed on the meal ticket. An RN confirmed the resident should have had the cup, and the SLP also stated the resident should have it.
A resident was improperly restrained in a geri chair with a lap tray, leading to psychosocial harm. The facility did not assess less restrictive alternatives and failed to provide necessary motion and exercise opportunities. The resident was left soiled and unattended for over an hour, and documentation was inadequate, lacking consent and verification of restraint release. The facility's investigation confirmed neglect due to staff oversight.
A documentation error led to five residents receiving an unnecessary second PPD test. The administering documentation was not properly recorded in the CareVue system, resulting in the Nurse Manager ordering a second test. The error was discovered after the tests were administered, and the residents were monitored for adverse reactions, with none reported.
The facility failed to store food according to professional standards, as observed during a survey. Issues included rotten and moldy produce, undated items, and expired products in the walk-in refrigerator, reach-in refrigerator, and walk-in freezer. The Hospital Supportive Services Supervisor confirmed these deficiencies and disposed of the affected items.
The facility failed to maintain an effective infection control program by not properly identifying Enhanced Barrier Precaution (EBP) isolation rooms for three residents with infections like MRSA and VRE. Observations revealed missing or incorrect isolation signs and lack of PPE outside the rooms, contrary to facility policy. The Infection Control Nurse confirmed these deficiencies.
A resident was left visibly soiled in a geri chair for over an hour in the dining room, despite multiple staff members entering and exiting the area. The resident showed signs of distress, but staff failed to notice or address his condition until much later, leading to a substantiated claim of neglect.
The facility failed to maintain a homelike environment in Room C 316, where a wall under the air conditioner was observed to be in poor repair, with exposed and rough wall plaster. A CNA and the DON acknowledged the issue and planned to inform maintenance.
A resident was left visibly soiled in a geri chair for over an hour, despite several staff members entering and exiting the dining room. The resident showed signs of distress, but staff failed to address his needs or reposition him. A recreation specialist noticed the resident was wet but did not inform others, leading to the resident remaining soiled until staff intervention.
A facility failed to properly investigate an injury of unknown origin involving a nonverbal resident with a history of false accusations and cognitive disorders. The investigation was limited to interviews with three staff members, without interviewing other residents or conducting body audits, contrary to the facility's normal procedures.
A facility failed to include a dementia diagnosis in the PASSR for a resident, despite the resident having been diagnosed with dementia. The PASSR included other diagnoses such as mental disorders and schizophrenia but omitted dementia. This was confirmed by the Director of Social Work during the survey.
The facility failed to update and implement comprehensive care plans for two residents, leading to unmet personal hygiene needs and neglect. One resident repeatedly refused care without interventions being documented, while another was left soiled and improperly positioned in a geri chair for over an hour, despite care plan requirements for regular checks. Staff failed to address these issues, resulting in substantiated claims of neglect.
A resident experienced a decline in Activities of Daily Living (ADL) after being physically restrained in a geri chair with a lap tray, preventing them from standing or walking. The facility did not assess the resident for less restrictive measures, such as a wheelchair, before using the restraint. The resident, who was previously able to walk independently, became totally dependent for all ADLs after the restraint was implemented. Despite being restrained, the resident continued to exhibit wandering behavior daily.
A resident was left visibly soiled for over an hour in the dining room, despite multiple staff members entering and exiting the area. The resident showed signs of distress and attempted to stand but was unable due to a lap tray. A recreation specialist noticed the resident was wet but failed to inform other staff, resulting in the resident remaining soiled until later addressed by nurse aides. The facility's investigation confirmed neglect due to the lack of communication and action.
Failure to Follow and Document Care Plan Interventions
Penalty
Summary
The facility failed to implement and carry out the comprehensive care plan for three residents reviewed during the survey. For Resident #2, the physician ordered Basaglar insulin 10 units subcutaneously once daily for diabetes mellitus baseline coverage with instructions to hold the medication if blood glucose was below 80 mg/dL, but the comprehensive care plan did not include interventions or parameters reflecting that order. The MAR showed that on 01/22/26, Basaglar was administered when the resident's blood glucose was 77 mg/dL, below the ordered hold parameter, and the ADON confirmed both the missing care plan interventions and that the insulin had been given despite the low blood glucose reading. For Resident #34, the care plan directed that Dycem be placed on the recliner, but an observation on 03/03/26 found no Dycem in the recliner, which was confirmed by Nurse #39 and acknowledged by RN #67 as being on the care plan.
Dining Service Not Coordinated for Resident at Shared Table
Penalty
Summary
The facility failed to promote dignity during dining by not ensuring that residents seated at the same table were served lunch at the same time. On 03/02/26, four residents were seated at a long table in the C wing dining room, and two residents received their meals at 12:25 PM while Resident #27 was not served until 12:38 PM; this timing was confirmed in an interview with Nurse #19 at 12:38 PM. On 03/03/26, two residents were seated at a table when state surveyors arrived at 12:15 PM, one resident was served at 12:32 PM, and Resident #27 was served at 12:40 PM; this was confirmed in an interview with the DON at 12:40 PM.
Incomplete PASRR Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was incomplete for two residents because the facility failed to ensure the Pre-admission Screening reflected pre-admission diagnoses. One resident’s admission diagnoses included schizoaffective disorder, bipolar disorder, major depressive disorder, generalized anxiety disorder, schizophrenia, and epilepsy, but the PASRR dated 10/10/24 omitted schizophrenia and epilepsy from Section III (Current Diagnosis) and Section V (Major Mental Illness), even though current medication orders and care plan focus areas addressed cognitive impairment, mood alterations, and seizure risks. Another resident’s diagnoses included unspecified dementia with anxiety, schizophrenia, impulse disorder, unspecified convulsions, and other seizures, but the updated PASARR dated 08/28/24 did not capture seizure disorder under Question 30 despite the seizure diagnosis being present at admission. The Administrator, ADON, and Regional Resource Administrator reviewed the findings and agreed the PASSR must be resubmitted to include all medical diagnoses.
Failure to Follow Diet and Insulin Orders
Penalty
Summary
The facility failed to follow physician orders for treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident choices, involving insulin administration and diet orders for two residents. For one resident, the dietary order specified a regular diet with thin consistency, no salt packet, food in bowls, double protein portions at all meals, and two peanut butter and jelly sandwiches on lunch and dinner trays. During lunch meal service, the resident’s tray did not contain the ordered sandwiches on two separate observations, and the resident indicated the sandwiches were missing. An RN later checked the order and returned with two peanut butter and jelly sandwiches, which the resident then ate. For another resident, the physician ordered Basaglar insulin 10 units subcutaneously once daily for diabetes mellitus baseline coverage, with instructions to hold the medication if blood glucose was below 80 mg/dL. Review of the MAR showed that the insulin was administered when the resident’s blood glucose was 77 mg/dL, below the ordered hold parameter. During interview, the ADON confirmed that the insulin had been given when the blood glucose level was below the physician-ordered parameter and acknowledged that this was not in accordance with the physician’s order.
Failure to Address Foot and Ankle Contracture
Penalty
Summary
Failure to provide care to maintain and/or improve range of motion (ROM) and mobility was identified for one resident with diagnoses of contracture of the foot and ankle. Record review and staff interview showed the resident had never been screened or evaluated for PT, and the only therapy-related documentation was a restorative exercise log. That log showed upper extremity active assisted ROM exercises, wheelchair push-ups, and lower extremity sitting exercises, but it did not address the resident’s foot and ankle contracture. Care plan review indicated the resident had bilateral ankle contractures and that therapy would screen, evaluate, and treat the resident per physician orders, but the record review and staff interview confirmed therapy had not screened, evaluated, or treated the resident.
Missing Assistive Device in Recliner
Penalty
Summary
The facility failed to ensure Resident #34 received the assistive device identified in the care plan to help prevent falls. During an observation at 2:23 PM on 03/03/26, Resident #34 was found without dycem in the recliner, even though the care plan called for it. Nurse #39 confirmed in the resident's room at 2:23 PM that the recliner did not have dycem in place.
Failure to Provide Ordered Slow-Sip Cup
Penalty
Summary
The facility failed to ensure Resident #4 was provided a slow-sip cup as listed on the meal ticket. At 12:30 PM on 03/02/26, in the dining room on C wing, the resident was observed with two cartons of milk with straws and no cups, despite the slow-sip cup being indicated. Nurse #19, who was present in the dining room, confirmed the resident should have had a slow-sip cup. Speech Language Pathologist #116 also stated she was not working on the resident not using a slow-sip cup and that the resident should have it. The care plan identified the resident as having potential nutritional risk related to a history of swallowing and choking problems, being edentulous, and having a mechanically altered diet, with slow-sip cup listed as an intervention.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, leading to psychosocial harm. The resident was placed in a geri chair with a hard lap tray, which prevented him from standing. The restraint was ordered due to an increased fall risk, but the facility did not assess the resident for less restrictive alternatives such as a wheelchair or walker. The resident was unable to release the lap tray independently, and multiple attempts to stand resulted in visible agitation and anxiety. Observations revealed that the resident was left in the geri chair for extended periods without being released for exercise, rest, toileting, or hygiene needs as required. The resident was found visibly soiled and was not attended to promptly by staff, despite being in the dining room for over an hour. The facility's policy on physical restraints was not followed, as the resident was not provided with the opportunity for motion and exercise for at least ten minutes every two hours. The facility's documentation was inadequate, with no signed consent from the resident's Medical Power of Attorney for the use of the restraint. The Treatment Administration Record lacked signatures or initials to verify that the resident was released from the restraint every two hours. The facility's Director of Nursing confirmed the absence of documentation but disagreed with the findings. The facility's investigation substantiated the allegation of neglect, as staff failed to notify others of the resident's needs.
Unnecessary Second PPD Test Administered Due to Documentation Error
Penalty
Summary
The facility failed to ensure that residents did not receive a second purified protein derivative (PPD) test when it was not warranted. This issue was identified for five out of eight residents reviewed for immunizations during the survey. The deficiency occurred because the administering documentation for the PPD tests was not properly recorded in the CareVue charting system used by the facility. Nurse Manager #58 discovered that the residents had already received a PPD test prior to the second administration. The deficiency was further compounded by the fact that the documentation for the initial PPD tests was not present in the system or in the designated 'to do' box where previous immunizations were supposed to be input. As a result, Nurse Manager #58 proceeded to put the order in the system for the PPD to be administered again to the residents. This led to the unnecessary administration of a second PPD test to the residents. Upon realizing the error, Nurse Manager #58 contacted the physician and pharmacist, who confirmed that the residents would not be harmed by the second test. However, the pharmacist noted that the results could read as a false positive, and the physician advised monitoring for a localized rash. The residents were observed for 72 hours with no adverse reactions reported. The deficiency highlights a lapse in the documentation process for immunizations within the facility.
Deficiencies in Food Storage Practices Identified
Penalty
Summary
The facility failed to ensure proper food storage in accordance with professional standards for food service safety, as identified during a long-term care survey. During a kitchen tour, several issues were observed in the walk-in refrigerator, including rotten and moldy peppers, watermelon, tomatoes, and lettuce, as well as an open carton with a busted egg. Additionally, several items such as butter, cheese, and raisins were found without proper dating. The Hospital Supportive Services Supervisor (HSSS) confirmed these observations and disposed of the affected items. Further inspection of the reach-in refrigerator revealed expired items, including Parmesan cheese and sliced ham, as well as undated Jell-O and opened cheese packs. The HSSS acknowledged these items were expired or undated and discarded them. In the walk-in freezer, three boxes of cod fillets were found without dates, which the HSSS also confirmed and disposed of. These deficiencies in food storage practices had the potential to affect more than a limited number of residents, given the facility's census of 51.
Failure to Properly Identify EBP Isolation Rooms
Penalty
Summary
The facility failed to maintain an effective infection control program by not properly identifying Enhanced Barrier Precaution (EBP) isolation rooms, which is crucial to prevent the spread of disease and infections. During an observation on August 13, 2024, it was found that the rooms of three residents, who were supposed to be under EBP due to infections like Methicillin-resistant Staphylococcus Aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE), lacked the necessary identifying isolation signs. Specifically, Resident #26's room did not have an isolation sign or personal protective equipment (PPE) available outside the room, while Resident #45's room lacked the required isolation sign. Resident #307's room had an incorrect sign indicating contact isolation instead of EBP. The Infection Prevention Nurse confirmed that the facility's policy, which mandates posting signs on the door outside the resident room indicating the type of precautions and PPE required, was not followed. This policy is essential for staff to know what PPE is required during care to prevent the spread of germs throughout the facility. The deficiency was confirmed on August 23, 2024, when the Infection Control Nurse acknowledged that the appropriate signs and PPE were not available as required.
Resident Neglect Due to Prolonged Soiling
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by the prolonged period during which the resident remained visibly soiled in the dining room. The incident involved a resident who was observed in a geri chair with a lap tray, with his pants visibly soiled in the groin area. Despite multiple attempts by the resident to stand up, which were unsuccessful due to the lap tray, staff members who entered the dining room did not notice or address the resident's condition. The resident exhibited signs of agitation and anxiety, such as bouncing his legs up and down, but eventually calmed down and fell asleep. Throughout the observation period, several staff members, including nurse aides and a recreation specialist, entered and exited the dining room without checking on the resident or noticing his soiled condition. It was not until approximately an hour later that staff members acknowledged the resident's state and began to address it. The facility's administrator was informed of the situation, and it was noted that the recreation specialist had failed to notify other staff members of the resident's needs, resulting in a substantiated claim of neglect.
Deficiency in Room Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the condition of a wall in Room C 316. During a tour, it was observed that an area on the wall under the air conditioner, measuring approximately two feet by two feet, was not covered by paint and exposed the white wall plaster underneath. The texture of this area was extremely rough, and some of the wall plaster was missing. This deficiency was noted during the long-term care survey process. A Certified Nursing Assistant acknowledged the issue and stated she would inform maintenance, and the Director of Nursing also indicated she would make maintenance aware of the wall condition.
Resident Neglect Due to Staff Inaction
Penalty
Summary
The facility failed to protect a resident from neglect, as observed during a survey. The resident was left visibly soiled in a geri chair with a lap tray down, restricting movement, for over an hour. The resident showed signs of distress, such as bouncing his legs anxiously and attempting to stand multiple times unsuccessfully. Despite several staff members entering and exiting the dining room, including nurse aides and a recreation specialist, none of them addressed the resident's needs or repositioned him. The recreation specialist noticed the resident was wet but failed to inform other staff members, leaving the resident unattended and soiled. The incident was reported to the facility administrator, who was informed that the resident had been visibly soiled from approximately 9:15 AM until 10:21 AM. The facility conducted an investigation and substantiated the allegation of neglect, as the recreation specialist admitted to forgetting to notify anyone about the resident's condition. This oversight resulted in the resident remaining in a soiled state for an extended period, highlighting a failure in the facility's duty to ensure residents are free from neglect.
Inadequate Investigation of Injury Allegation
Penalty
Summary
The facility failed to properly investigate an allegation of injury of unknown origin involving a resident with a complex medical and behavioral history. The resident, who is nonverbal and communicates through nods and a dry erase board, was found with a bruise on her arm. When asked if the bruise was caused by staff pulling her up, the resident nodded yes. The resident has a history of making false accusations against staff and has been diagnosed with several cognitive and psychiatric disorders, including dementia and schizoaffective disorder. The care plan indicates that the resident should be lifted using a lift, and she could not name or describe the alleged perpetrator. The investigation into the incident was inadequate, as it only included interviews with three staff members who were on shift at the time, all of whom denied witnessing or being involved in the incident. The facility's normal process for investigating such allegations includes interviewing all staff and residents involved or on shift, as well as conducting body audits on residents who cannot be interviewed. However, in this case, no other residents aside from the alleged victim were interviewed, and no body audits were conducted. The Social Services Director was unsure why these steps were not taken, indicating a failure to follow the facility's established investigation procedures.
Omission of Dementia Diagnosis in PASSR
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASSR) for a resident included all pertinent diagnoses. Specifically, the PASSR for a resident, identified as #42, did not contain a dementia diagnosis, despite the resident having been diagnosed with dementia on 12/10/19. The PASSR, dated 10/22/19, included diagnoses such as mental disorders, delusions, schizophrenic disorder, schizophrenia, and unspecified neurocognitive disorder, but omitted the dementia diagnosis. This omission was confirmed by the Director of Social Work during the survey process.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to update and implement a person-centered comprehensive care plan for Resident #26, who expressed a need for personal hygiene care, including a haircut, shave, and shower. Despite having a shower schedule twice a week, the resident's care plan did not address his repeated refusals of care, as documented on several occasions in July 2024. The Director of Nursing acknowledged the absence of a care plan or interventions for the resident's refusal of care, which is contrary to the facility's policy requiring documentation and appropriate changes to the care plan when care is refused. Resident #48 was found in a geri chair with a hard lap tray, preventing him from standing, and was visibly soiled in the groin area. Despite the care plan's requirement for checks every 30 minutes for proper positioning and every 2 hours for exercise, rest, toileting, and hygiene needs, staff failed to attend to the resident's needs. Multiple staff members, including nurse aides and a recreation specialist, entered and exited the dining room without addressing the resident's soiled condition or checking his positioning, leading to the resident remaining soiled for over an hour. The facility's administrator was informed of the neglect, and an investigation substantiated the claim due to the recreation specialist's failure to notify staff of the resident's needs. The lack of adherence to the care plan and failure to provide timely care resulted in the resident being left in an uncomfortable and potentially harmful situation, highlighting a significant deficiency in the facility's care planning and implementation processes.
Failure to Prevent ADL Decline Due to Restraint Use
Penalty
Summary
The facility failed to ensure that a resident did not experience a decline in Activities of Daily Living (ADL) unless it was unavoidable. This deficiency was identified during a survey process where it was found that a resident was physically restrained in a geri chair with a lap tray, preventing them from standing or walking. The resident, who was previously able to walk independently, was placed in the chair due to concerns about falls. However, the facility did not assess the resident for less restrictive measures, such as a wheelchair, before resorting to the restraint. Interviews with staff revealed that the resident could not release the lap tray independently and that the facility did not evaluate the resident for a wheelchair because they believed the resident would slide out of it. The Minimum Data Set (MDS) assessments for the resident showed that prior to the use of the restraint, the resident was steady while walking and required only partial to moderate assistance for ADLs. After the restraint was implemented, the resident became totally dependent for all ADLs, and walking was no longer attempted due to safety concerns. Despite being restrained, the resident continued to exhibit wandering behavior daily. The facility's Director of Nursing (DON) and MDS Coordinator confirmed that the resident was able to ambulate independently before the restraint was ordered, and no assessment for a wheelchair was conducted.
Neglect in ADL Care for a Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a dependent resident, identified as Resident #48, who was left soiled for an extended period. The incident was observed by a surveyor on the morning of August 13, 2024, when Resident #48 was found in the dining room, visibly soiled and unable to stand due to a lap tray on his geri chair. Despite multiple staff members entering and exiting the dining room, including Nurse Aide (NA) #8, NA #57, and Recreation Specialist (RS) #69, none of them addressed the resident's condition or repositioned him. RS #69 acknowledged the resident was wet but failed to inform other staff members, resulting in the resident remaining soiled until approximately 10:21 AM. The resident exhibited signs of distress, such as bouncing his legs anxiously and attempting to stand multiple times without success. The facility's administrator was informed of the situation, and it was noted that the resident had been visibly soiled since at least 9:15 AM. The facility conducted an investigation and substantiated the allegation of neglect, as RS #69 admitted to forgetting to notify anyone about the resident's needs. The report highlights a significant lapse in care and communication among the staff, leading to the resident's prolonged discomfort.
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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 Beckley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Lodge | 1.3 mi | ★★★★★ | 17 | 0 |
| Beckley Healthcare Center | 3.3 mi | ★★★★★ | 21 | 0 |
| Raleigh Center | 4.3 mi | ★★★★★ | 13 | 0 |
| Hilltop Center | 10.4 mi | ★★★★★ | 15 | 0 |
| Hidden Valley Center | 14.4 mi | ★★★★★ | 9 | 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.