Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Mansfield Place during CMS and state inspections, most recent first.
A resident was struck in the back by a tall tray cart pushed by a CNA in a busy hallway, causing the resident to fall and sustain severe head injuries, including tSAH, an intraparenchymal hemorrhage, and a subdural hematoma. The resident was unconscious briefly after the fall, required emergency transfer by Life Flight, and later had a palliative care consult with discussion of comfort care after being determined DNR.
Failure to report an abuse allegation within the required timeframe. A resident told SW that a blonde-haired aide spoke to her hatefully after she had soiled her brief, and later described the aide as a tall blonde with a ponytail who yelled at her because she had an accident. Record review showed the facility did not notify State Agencies within the 2-hour window required by policy and CMS guidance.
Dirty Spoon Found on Meal Cart During Lunch Service. During lunch service, a tall food cart was brought into the dining hall with a dirty spoon on top and a Styrofoam cup next to it for a resident meal. The Dietary Supervisor confirmed the cup belonged to a resident and was listed on the meal ticket, and acknowledged the spoon was not supposed to be there and was not in line with standards of practice.
Failure to Document Required Seat Belt Releases: A resident who could not self-release a seat belt due to medical conditions had an order for release every two hours, repositioning, skin checks, proper attachment, and pericare, but the record contained no documentation that the belt was released and the resident was checked as ordered. Staff interviews showed CNAs did not have a place to chart the checks, and an RN and LPN were unsure where to document restraint monitoring.
Inaccurate MDS Documentation of Wounds and Change in Condition: A resident developed a pressure ulcer and other toe injuries, but the MDS did not accurately reflect the wound status or location. Record review showed inconsistent wound documentation across nursing notes and the MDS, and the DON acknowledged charting consistency issues and that staff sometimes used different names for wounds.
The facility failed to complete PASRR accurately for two residents reviewed. One resident had a Bipolar Disorder diagnosis that was not marked on the PASRR, and another resident had diagnoses including anxiety disorder, schizoaffective disorder, and unspecified depression, but the PASRR only checked Major Depression. The SW confirmed the omissions and stated that depression should be checked under Other on the PASRR.
A resident who could not self-release a seatbelt had an order for the belt to be released every two hours with repositioning, skin checks, proper attachment, and pericare, but record review found no documentation that the checks were completed. Staff interviews showed CNAs did not have a place to chart the checks, an RN was unsure where to document restraint care, and an LPN trainer could not locate the charting area; the DON stated the order had not been entered as a task and therefore did not appear on the TAR.
A facility failed to document pharmacy reviews/recommendations in resident charts for several residents. Record review showed that three residents had no pharmacy review noted in their records for the month in question, and the DON stated the reviews had been completed but were not entered into the charts. A pharmacy report later confirmed the reviews were done, but the documentation was missing from the medical record.
Failure to Supervise Resident During Tray Cart Transport
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and was protected from avoidable accident hazards when a resident was struck by a tall tray cart pushed by a CNA in a high-traffic hallway. Record review showed that the resident was sitting at the nurse’s station, then stood facing the dining room with the CNA behind him pushing the cart. The CNA struck the resident in the back with the tray cart, causing him to fall forward onto his left side. RN staff responded immediately, a rapid response was called, and the resident was transported for emergency care. The resident was later diagnosed in the ED with an acute extensive traumatic subarachnoid hemorrhage, an acute left frontal intraparenchymal hemorrhage, and a left parafalcine subdural hematoma. He was life-flighted as a Priority Two Trauma to another hospital because of the severity of his injuries. Facility records noted that he was unconscious for about one minute after the fall, and the hospital later initiated a palliative care consult and discussed comfort care after determining the resident was DNR.
Failure to Report Abuse Allegation Within Required Timeframe
Penalty
Summary
The facility failed to report a possible abuse allegation to State Agencies within the required two-hour timeframe. During record review, a social worker documented that after receiving information from PT, the resident was hesitant to discuss the concern and repeatedly stated, "I don't want to get her in trouble." The resident reported that a blonde-haired staff member had spoken to her "a little bit hatefully" and believed it was because she had soiled her brief. The resident could not identify the staff member beyond the color of the aide's hair and said the incident happened a couple of days earlier. The record review showed the facility had until 2:21 PM on 7/21/2025 to notify State Agencies of the potential abuse incident, but the report indicates this was not done within that timeframe. On 7/22/2025, the resident again stated she was upset and crying about how she was made to feel, and described the staff member as a tall blonde aide with a ponytail who yelled at her because she had an accident. The facility policy reviewed stated that all violations must be reported immediately, but no later than two hours after the allegation is made.
Dirty Spoon Found on Meal Cart During Lunch Service
Penalty
Summary
F0880 Infection Control was not met based on a random observation of lunch cart service and staff interview. During lunch service, a tall food cart was brought into the main dining hall with a dirty spoon sitting on top of the cart and a Styrofoam cup placed next to it, both intended for a resident meal. The Dietary Supervisor stated the cup was for a resident and had been placed on top because it did not fit in the tray cart, and confirmed the cup was identified on the resident’s meal ticket as soda in a cup on top of the meal cart. When asked about the spoon, she removed it and took it back into the kitchen, confirming it was not supposed to be there and was not in line with standards of practice.
Failure to Document Required Seat Belt Releases
Penalty
Summary
The facility failed to follow the order to release Resident #7 from a seat belt every two hours, along with repositioning, skin checks, proper attachment of the seat belt, and pericare. Record review showed the order was placed on 2/3/25 with instructions to prevent skin breakdown and to perform the release and checks every two hours at 07:00, 09:00, 11:00, 13:00, 15:00, and 17:00, but there was no documentation showing the belt was released and the resident was checked every two hours as ordered. The resident was unable to self-release the belt due to medical conditions, and staff interviews showed the CNA stated the resident was checked every two hours when up but that CNAs did not have a place to chart it, while the RN and LPN were unsure where to document restraint checks. The DON stated the order had not been made into a task in the system and therefore did not appear on the TAR, and no documentation could be located for the required releases and checks.
Inaccurate MDS Documentation of Wounds and Change in Condition
Penalty
Summary
The facility failed to complete a change in condition MDS after Resident #9 developed a pressure ulcer and failed to accurately document the status of the resident’s injuries on the 6/26/25 MDS. Record review showed the 6/29/25 MDS indicated an unhealed pressure ulcer/injury in section M0210, but section M0300 did not identify a stage 4 or unstageable pressure ulcer on the left 4th toe, and the wound was not resolved until 6/30/25 according to charting. The MDS also stated there was a deep tissue injury with no location given, and section M1040 indicated there were no other wounds, while the left foot 3rd toe abrasion was not resolved until 6/30/25. Wound notes showed a left 4th toe wound was first found on 6/6/25, reassessed and updated on 6/9/25, continued on weekly assessments on 6/16/25 and 6/23/25, and on 6/30/25 both the left 3rd and 4th toe injuries were documented as resolved. The DON stated she was aware of some consistency issues when charting wounds on in-house forms and the MDS, and that different nurses sometimes call wounds by different names.
Inaccurate PASRR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure Preadmission Screening and Resident Review (PASRR) was completed accurately for 2 of 5 residents reviewed in the PASRR care area. For Resident #2, the most recent PASRR completed on 02/17/25 showed no diagnoses checked, even though record review showed a primary diagnosis of Bipolar Disorder dated 04/21/25; the Social Worker confirmed on 07/27/25 that Bipolar Disorder was not marked on the PASRR. For Resident #23, record review showed diagnoses of Anxiety disorder, Schizoaffective disorder, and Depression, unspecified, but the PASRR only checked Major Depression. During interview on 07/23/25, the Social Worker stated that if a resident has a diagnosis for Depression, Major Depression is marked on the PASRR and confirmed that Depression should be checked under Other on the PASRR.
Failure to Document Required Two-Hour Seatbelt Checks
Penalty
Summary
The facility failed to follow the established care plan and physician order for Resident #7, who was unable to self-release the seatbelt due to medical conditions. The order, placed on 2/3/25, directed staff to release the seatbelt every two hours, reposition the resident, perform skin checks, ensure proper attachment of the seatbelt, and provide pericare, with the stated purpose of preventing skin breakdown. Record review showed no documentation that the belt was released and the resident was checked every two hours as ordered. During interviews on 7/23/2025, a CNA stated that when the resident was up, staff checked him every two hours, but CNAs did not have a place to chart it. The CNA also stated the resident was not up for very long each day because he became upset and wanted to return to his room. An RN who was newly hired and still in training was unsure where to chart a restraint in the system, and an LPN trainer was also unable to find where to document the checks. The DON stated that no documentation could be located for the required releasing and checking, and explained that the order had not been made into a task in the system and therefore did not appear on the TAR.
Missing Documentation of Pharmacy Reviews in Resident Charts
Penalty
Summary
The facility failed to maintain resident medical records in accordance with accepted professional standards by not documenting that residents received Pharmacy Reviews/Recommendations for the month of June 2024. During record review, residents #2, #6, and #18 were found to have no pharmacy recommendation or review noted in their charts for that month. In interview, the DON stated that the pharmacy reviews had been completed and that a list existed, but the reviews were not noted in the residents' charts. The DON then provided a pharmacy report showing that residents #2, #6, and #18 did in fact receive Pharmacy Reviews/Recommendations for the month in question, confirming the documentation was missing from the medical record.
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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 Philippi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tygart Valley Health & Rehabilitation | 10.1 mi | ★★★★★ | 12 | 0 |
| Rosewood Center | 12.8 mi | ★★★★★ | 16 | 0 |
| Taylor Healthcare Center | 13.4 mi | ★★★★★ | 5 | 0 |
| Maplewood Healthcare Center | 13.6 mi | ★★★★★ | 8 | 0 |
| Holbrook Healthcare Center | 14.7 mi | ★★★★★ | 0 | 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.