Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Marmet Center during CMS and state inspections, most recent first.
Failure to designate a qualified Infection Preventionist. The DON stated the facility's Infection Preventionist had resigned, and an RN with Infection Preventionist training said she was only available for infection control training and was not involved in day-to-day IP duties because she directed the dementia unit. The DON later said a new Infection Preventionist had started, but no further information was provided before the survey ended.
Surveyors found that meals were not consistently served in an appealing manner, with several residents reporting that the food was not good and that they often chose alternate menu items or food brought by family. Observations showed a plated chicken entrée where the dinner roll was placed on the same plate and became soggy from tomato sauce, and a puree meal with BBQ formed into a firm round shape, runny baked beans, and stiff puree bread that was difficult to mash. In the dining room, multiple residents left before dessert was offered and therefore did not receive it, and staff acknowledged dessert should have been served with the meal.
A facility failed to develop and implement activity care plans for two residents. One resident said she mostly stayed in her room and was only asked about bingo, while another said activities seemed pointless and she usually did not attend. Surveyors found no activity care plans in the records, and the Administrator confirmed they were not present.
The facility failed to complete timely AIMS assessments for residents receiving antipsychotic medications and failed to monitor a resident’s peripheral IV access. A resident on Zyprexa had only one AIMS on record, another resident on Risperdal had a long gap between AIMS assessments despite repeated pharmacist recommendations, and a third resident receiving IV cefazolin had no documented IV site care or observation, with an undated dressing noted on the IV site.
Failure to document house supplement intake during weight loss. A resident had significant wt loss and was ordered a house supplement for wt loss; intake was initially recorded on the MAR, but after the order changed to BID, the supplement consumption was no longer documented. The DON confirmed the missing documentation, and the RD agreed it was important to know how much supplement the resident was consuming.
Surveyors found a multi-use PPD vial in the med room refrigerator that was not dated when first opened and had no pharmacy delivery label showing when it entered the facility. They also found several insulin pens for multiple residents that were either past the 28-day discard period or not dated when first accessed, including Lispro, Novolog, Lantus, and Humalog pens used for blood glucose coverage.
Meals were not served in a sanitary manner and food service equipment was not kept clean. Staff were observed using gloved hands instead of utensils for food items, touching multiple surfaces while gloved, failing to wash hands before resuming service, and continuing meal prep without changing gloves after leaving the serving area. Steam wells in the dining room kitchenette also contained food debris after breakfast service had ended, and a pureed meal was observed with poor plating and texture.
The facility failed to maintain an infection prevention and control program when infection surveillance was not performed for several months after the IP resigned. During a dressing change for a resident with EBP orders and left foot pressure ulcers, an NA assisting with positioning wore only gloves while her clothing and bare arms contacted the resident and bed linens. Two bedpans were also found in a bathroom between rooms C24 and C26 without bags or labels.
A deficiency was cited when a resident receiving the antipsychotic Risperdal for schizophrenia, with documented hallucinations, delusions, and aggressive verbal behaviors, had no recorded behavioral monitoring or non-pharmacologic interventions in the MAR or other medical records, despite facility policy and specific physician orders requiring such documentation. The care plan listed multiple behavioral and environmental interventions and required monitoring for side effects and behavioral triggers, but surveyors and the DON confirmed that these were not documented. Surveyors also found that another resident was overly medicated, resulting in drowsiness and restraint, contributing to the finding of unnecessary psychotropic medication use.
A resident with a physician’s order for double entrée portions at meals was observed receiving only a single BBQ sandwich, despite the tray ticket specifying a double entrée. During the meal, the NA assisting the resident left the table briefly, during which time the resident consumed almost the entire sandwich and ate meat that had fallen onto their clothing. When the NA returned and was informed of the double-entrée order, the NA stated they were unaware of the order. Record review confirmed the active order for double entrées, and the observation showed the meal served did not match the ordered diet.
A resident with a BIMS of 14 was moved to a different room without being told the reason in advance and said she would have preferred to stay in her old room. She found another resident in her bed and was then informed by staff that she had been moved. The AD said room changes were part of his responsibility and acknowledged that more notice would have been a good idea.
Incomplete and inaccurate MDS assessments were identified for two residents. One resident’s MDS incorrectly coded a wound infection, and another resident’s quarterly MDS incorrectly coded a hip fracture and other fracture, even though the medical record did not support those diagnoses during the look-back period. An LPN and the Administrator confirmed the coding errors were pulled from older MDS records.
A resident with a tube feeding order for Isosource 1.5 at 60 mL/hr for 18 hours daily was observed with no feeding running during the scheduled start time, and the DON confirmed it should have been hanging. An LPN stated she forgot and missed her window, yet had already signed as if the feeding had been given. The next morning, no tube feed was hanging and an LPN said she had already stopped it for the day; the CRRN confirmed the feeding did not appear to have run for the ordered 18 hours needed to deliver the full volume.
A resident who lacked capacity had the 2025-2026 COVID-19 vaccine declined by the representative, but the MAR showed the vaccine was still given. The DON confirmed the vaccine was administered despite the documented refusal and the facility's consent policy.
The facility did not maintain a safe, sanitary, and comfortable environment when mice droppings were reported and observed in multiple areas, including behind furniture in two resident rooms and on the floor of the Activities Director’s office on B Hall. Anonymous interviews indicated prior sightings of mouse droppings in resident areas, and a surveyor later confirmed droppings in a staff office, with facility leadership acknowledging these findings in a facility with 89 residents.
The facility did not maintain required refrigerator temperatures in the Rehab pantry, with several instances of temperatures above 41°F and missing documentation for temperature checks. These issues were confirmed by the DON and Administrator.
Surveyors identified unsanitary conditions in the Rehab pantry room, including the presence of gnats and exposed damp wood on the sink countertop. These findings were confirmed by facility staff and had the potential to affect multiple residents.
During a COVID-19 outbreak, two nurse aides were observed on a resident hall with their N-95 masks pulled down under their chins, contrary to facility policy and CDC guidance requiring staff to wear well-fitting masks. The Administrator confirmed that all staff were expected to wear N-95 respirators during an active outbreak, and acknowledged the non-compliance.
A resident placed on 1:1 monitoring was required to keep their door open at all times, including during toileting, bathing, and changing clothes, resulting in a lack of privacy and dignity. The resident reported embarrassment and feeling disrespected by staff, while facility leadership acknowledged staff fears but did not provide adequate alternatives to maintain the resident's privacy.
Staff failed to report two incidents involving a resident's disruptive and aggressive behaviors, which led to police involvement, to the appropriate State agencies as required. Despite staff concerns and law enforcement being called due to suspicion of a crime, the facility did not notify authorities about the changes in the resident's condition or the suspected crime.
A resident exhibiting disruptive behavior was placed on one-on-one observation without a physician's order, and the facility did not inform the physician when the resident refused a recommended psychiatric evaluation. Record review and staff interviews confirmed the absence of a required order for the observation status.
A resident's West Virginia Physician Order for Scope of Treatment (POST) form was found to be incomplete, lacking both the preparer's signature and date, as identified during a record review and confirmed by staff interview.
Surveyors found an unlocked and unattended medication cart in a hallway, with an LPN leaving it accessible while attending to residents. In a separate incident, a resident with mild cognitive impairment was found to have razors stored in her bedside table, contrary to facility policy requiring such items to be secured. The DON confirmed both practices were not in compliance with facility procedures.
The facility did not ensure that a licensed pharmacist completed and documented monthly medication regimen reviews for several residents, nor did it ensure that physicians addressed pharmacy recommendations as required. For example, a resident with a recent fall had pharmacy recommendations for medication changes that were not reviewed or addressed by the physician, and two other residents had missing pharmacy reviews for multiple months, as confirmed by staff.
Surveyors found that multiple multi-dose medication bottles were stored past their expiration dates and three insulin pens were not dated when first accessed. An LPN confirmed the expired medications and undated insulin pens during a medication cart inspection.
Staff in the Alzheimer's unit served lunch using incorrect utensils, resulting in failure to provide the specified portion sizes of turkey, dressing, and peas as outlined in the facility's menu and recipes. The Activity Director reported not having the correct utensils, and the administrator confirmed this issue.
Surveyors found that prepared foods in a unit refrigerator were not labeled or dated, and staff could not confirm when the items were placed there. In the kitchen, boxes were stored directly on the freezer floor, and a blanket was used to absorb water in the food service area, all contrary to facility policy and professional standards.
An Activity Director was observed preparing and serving food to residents without possessing a required food handler's card, as confirmed by both the staff member and the administrator. This was not in compliance with local health department regulations, which mandate food handler training for anyone handling or serving food.
The facility did not maintain complete and accurate medical records for two residents. One resident's nursing evaluations continued to document an indwelling urinary catheter after it had been removed, and another resident's POST form lacked a required physical signature from the medical power of attorney, despite the representative's frequent visits.
Surveyors observed that two residents with PEG tubes did not have Enhanced Barrier Precautions (EBP) signs posted on or near their room doors, as required by facility policy. Although PPE was available, the absence of proper signage indicated a failure to fully implement the infection prevention and control program for residents with indwelling medical devices.
Surveyors found an electric stove in the Alzheimer's unit kitchen with only one functioning stove eye, while the other three were missing and covered with a glass serving plate. An LPN stated the stove had been like this for a while and was sometimes used by activities staff. The administrator confirmed the missing stove eyes and the use of glass plates as covers, contrary to facility policy requiring equipment to be maintained in safe working condition.
Gnats were observed in the bathrooms of two resident rooms and the administrative conference room, indicating the facility did not have an effective pest control program in place.
A resident's PASARR did not reflect their preadmission diagnoses of schizophrenia and anxiety disorder, even though the resident was receiving medications for these conditions. The social worker confirmed the omission and was unable to provide an updated PASARR.
A resident receiving apixaban for atrial fibrillation did not have a care plan addressing anticoagulant use or monitoring for bleeding, despite the known risks. The absence of this care plan focus and related interventions was confirmed by facility staff.
A resident dependent on staff for activities of daily living did not consistently receive twice-daily oral care as required. Despite a care plan indicating the need for staff assistance and repeated concerns raised by the resident and family, documentation showed frequent omissions in both morning and evening oral care, and interviews confirmed the deficiency.
Surveyors found that the facility did not follow physician orders for two residents: one did not receive weekly weights as ordered after experiencing weight loss, and another with a hand contracture did not have a prescribed resting hand splint applied for the required duration on multiple occasions. These deficiencies were confirmed by nursing leadership and through direct observation and resident interview.
A resident experienced significant weight loss over two months, with records showing incomplete and inaccurate documentation of meal intake. Staff interviews indicated that the admission weight may have been incorrectly entered from hospital records instead of being measured, and the lack of proper meal intake documentation hindered the ability to determine the cause of the weight loss.
A resident received PRN acetaminophen for pain, but staff failed to document the location and severity of pain prior to administration, as required by facility policy. The effectiveness of the medication was noted, but no pain assessment was recorded in the MAR or nurse's notes.
A resident was served a meal that did not match their documented dietary preferences and requirements, receiving turkey, stuffing, and peas instead of the specified chicken sandwich, salad, and baked potato. The resident, who was cognitively intact, noted the discrepancy, and a dietary aide confirmed the unavailability of the requested meal items.
A resident on comfort care received an incorrect dosage of Morphine Sulfate due to a physician assistant's order being entered incorrectly as 2.5 ml instead of 2.5 mg. The LPN administered the medication without questioning the order, believing it was justified for comfort care. The error was discovered after the resident received two doses, highlighting a communication breakdown in the facility.
The facility failed to ensure a clean, comfortable, and homelike environment, with issues such as black scuff marks, peeling paint, and evidence of spiders found in various areas. The Maintenance Director and Assistant were aware of these issues, focusing on addressing safety concerns first.
The facility failed to ensure that three residents were seen by a physician at the required intervals. The residents were not seen by a physician every 60 days as mandated, with gaps in visits noted. Although PAs had seen the residents, these visits did not alternate with physician visits as required. The administrator and DON confirmed the deficiency.
The facility failed to maintain a safe and clean environment for residents, with issues such as detached trim, trash, and debris in rooms, a trail of brown substance in a bathroom, and mouse droppings in a wardrobe. Staff members, including the DON and Housekeeping Manager, acknowledged these deficiencies.
A resident with an eating disorder and ALS experienced significant weight loss due to inadequate nutritional care and insufficient documentation of meal intakes. Despite being on a regular diet and requiring feeding assistance, the facility failed to maintain acceptable nutritional parameters, as confirmed by the RD and DON.
The facility failed to provide a clean and safe environment, with trash and food found in a resident's room, dirty nightstands, a soiled blanket, and unclean sit-to-stand lifts. Staff acknowledged these issues, and the facility's infection control policies require equipment to be cleaned between residents.
The facility failed to administer medications on time for three residents, with delays ranging from over an hour to more than eight hours. This deficiency was confirmed by the DON, indicating systemic issues in medication management.
A resident at risk for falls due to cognitive loss and impaired mobility did not have their care plan implemented, as a radio meant to be within reach was missing. The DON confirmed the family had taken the radio home.
The facility failed to store respiratory equipment properly, as observed with several residents' nebulizer masks and a nasal cannula. A resident's nebulizer mask was found on a nightstand without a respiratory bag, confirmed by an LPN and the DON. Another resident's nasal cannula was on the floor, acknowledged by an LPN. These instances indicate non-compliance with respiratory care standards.
The facility failed to maintain proper records and reconciliation of controlled substances. Observations revealed that lorazepam and clonazepam tablets were improperly taped back into medication cards by LPNs, which was confirmed as unacceptable by the DON. Additionally, tramadol was signed out but not documented as administered for a resident, indicating discrepancies in medication administration records.
The facility failed to maintain infection control standards, with soiled linens left untied in rooms, a used wash basin on the floor, a dirty urinal with dried substance, and a used bed pan improperly stored. These deficiencies were confirmed by nursing staff and the DON.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. During record review and staff interview, the Director of Nursing stated that the facility's Infection Preventionist had resigned in February. Registered Nurse #12 provided a certificate showing Infection Preventionist training and stated she was available to assist with staff training in infection control as needed, but she was not involved in day-to-day Infection Preventionist activities because she served as the director of the dementia unit. The DON later stated that an Infection Preventionist had been hired and started the day before the second interview, and no further information was provided before the survey process ended.
Unappealing Meal Service and Inconsistent Dessert Provision
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure meals were served in an appealing and palatable manner. During resident interviews, multiple residents reported dissatisfaction with the quality of the food, stating that the food was “not real good most of the time” and that they often relied on the always-available menu or food brought in by family. During a noon meal observation, a plated entrée of chicken cacciatore, rice, and Capri vegetable blend was served with a dinner roll placed directly on the plate, resulting in the roll becoming soggy from tomato juices. Several residents stated that this occurred regularly and expressed a preference for the bread to be bagged separately. The dietary manager confirmed that the dinner roll had been plated on the entrée plate and had become soggy. Further observations in the dining room showed that several residents did not receive dessert because they left the dining room before nursing assistants offered it, and staff acknowledged that dessert should have been served with the meal. In addition, the presentation of a puree meal was found to be unappealing: the BBQ component was in a firm round form, the baked beans were smooth but running on the plate, and the puree bread was firm and stiff, making it difficult to smash with a fork. A nursing assistant confirmed that the vegetables and bread on puree plates were always presented in this manner, and the dietary manager verified that both the missed desserts and the puree plate presentation were not appealing.
Missing Activity Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for activities for Resident #2 and Resident #12. During record review, no care plan for activities was found for either resident. Resident #2 stated she did not go to activities much, preferred to stay in her room, and said staff only asked if she wanted to play bingo. Another resident stated she usually did not go to activities because they seemed pointless, and that someone came in every day or so to talk with her, which she liked. The deficiency was identified during the annual survey when surveyors reviewed the records on 04/20/2026 and could not locate activity care plans for the two residents. The survey findings were based on resident interviews and record review showing that the residents had limited participation in activities and that the facility did not have documented activity care plans in the chart. When the Administrator was interviewed, she stated the care plans were not in the record. She said the activities director had been doing audits to ensure care plan assessments and related items were in the system, but the activities director was on leave and unavailable. She also stated the assistant could complete the assessments but could not input anything, and that the MDS person did that.
Missed AIMS Monitoring and IV Access Care
Penalty
Summary
The facility failed to provide care and services according to orders, resident preferences, and accepted standards of practice by not completing timely and consistent Abnormal Involuntary Movement Scale (AIMS) assessments for residents receiving antipsychotic medications. Resident #76 was prescribed Zyprexa from 07/10/23 to 09/20/25, but the only AIMS assessment found in the record was dated 01/10/24. During interview, the DON confirmed that AIMS assessments should be completed every 6 months for residents on psychotropic medications. Resident #69 had been receiving Risperdal since 2023 for schizophrenia with hallucinations and delusions. AIMS assessments were documented on 01/04/24 and 07/03/24, but no further assessments were completed until 03/02/26. The consultant pharmacist repeatedly documented that antipsychotics can cause tardive dyskinesia and other movement disorders and recommended movement testing such as AIMS or DISCUS at least every six months while the resident remained on antipsychotic therapy. On 03/23/26, an AIMS assessment documented minimal movements of the muscles of facial expression and minimal tongue movements. The DON confirmed that AIMS assessments were not performed between 07/03/24 and 03/02/26. The facility also failed to monitor peripheral IV access for Resident #56, who was admitted from the hospital with orders to continue IV antibiotics through an existing peripheral IV. The resident had an order for cefazolin sodium every 8 hours, but there were no orders for observation or care of the peripheral IV access, and the TAR, MAR, and progress notes contained no documentation of IV site observation or care. During observation, the resident had a pump for IV medications or fluids and a dressing over the right antecubital IV site that was not dated. The DON stated she did not know whether the dressing had been changed since admission and later wrote an order for IV catheter site dressing changes and daily measurement of external catheter length.
Failure to Document House Supplement Intake During Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met when the facility failed to document the percentage of a house supplement consumed by Resident #29 during a period of significant weight loss. Resident #29 weighed 106 pounds on 10/14/2025 and 86 pounds on 04/06/2026, representing an 18 percent weight loss in six months. On 03/25/26, the resident was ordered a house supplement once daily for weight loss, and the amount consumed was recorded on the MAR. On 04/02/26, the order changed to twice daily, but the resident's supplement consumption was no longer recorded on the MAR. A quarterly nutrition note on 04/13/26 stated there were no new losses since house supplements BID were in place. On 04/20/26, the DON confirmed the supplement consumption had not been recorded since 04/02/26, and the RD agreed it would be important to know how much supplement Resident #29 was consuming.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications in accordance with accepted standards of care. During investigation of medication storage and labeling practices, surveyors found a multi-use vial of Tubersol purified protein derivative (PPD) in the medication room refrigerator that had not been dated when first opened, and there was no label on the vial packaging showing when it had been delivered from the pharmacy. RN #43 confirmed the vial had not been dated when first accessed and that there would be no way to determine when it had been in use for 30 days. The package insert stated that a vial of Tubersol PPD that has been entered and in use for 30 days should be discarded. Surveyors also found multiple insulin pens that were not managed according to the facility’s labeling and expiration requirements. In the medication room, a Lispro insulin multi-dose pen for Resident #59 was dated as opened on 03/15/26, and RN #43 confirmed it had been in use longer than 28 days even though the label stated to discard it after 28 days. On the D hallway medication cart, a Novolog insulin pen for Resident #44 was also labeled as opened on 03/15/26 and was past the 28-day discard timeframe. In addition, Lispro insulin pen for Resident #44, Lantus insulin pen for Resident #32, two Humalog insulin pens for Resident #32, and a Lantus insulin pen for Resident #6 were not dated to show when they were first opened, and all were labeled to be discarded within 28 days. The residents involved were currently prescribed these insulins for coverage of elevated fingerstick blood glucose checks.
Unsanitary food handling and unclean steam wells during meal service
Penalty
Summary
Meals were not served in a sanitary manner and food service equipment was not kept clean during observations in the main dining room and kitchenette. During meal service, a server/dietary aide used gloved hands to obtain dinner rolls instead of utensils, used a fork for chicken, and touched multiple surfaces with gloved hands before placing a dinner roll on a plate. A lead cook verified the practice and corrected it. In the dining room kitchenette, steam wells contained moderate amounts of food debris, including egg and oatmeal, floating in the water after breakfast service had ended, and the debris was still present on a later observation. During another meal service, a server/cook did not wash hands after coming from the kitchen to the serving area, put gloves back on, and began meal service until stopped and instructed to wash hands and re-glove. The same server/cook also used tongs for a hamburger bun but then used gloved hands to open the bun without changing gloves or washing hands unless instructed. In the kitchen tray line, a staff member left the serving area while wearing gloves, obtained extra plates and bases, returned, and continued tray line work without changing gloves or washing hands. The pureed meal observed at that time had beans running on the plate, and the pureed bread was described as very firm and thick in appearance.
Infection control surveillance, EBP use, and bedpan storage deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Review of the Infection Surveillance Reports for May 2025 through April 2026 showed no infections documented in February, March, and April 2026. On 04/21/2026, the DON stated the facility's Infection Preventionist had resigned in February and that no one had been available to perform infection surveillance since that time. On 04/22/26, the DON stated an Infection Preventionist had been hired and started the day before. The facility also failed to follow enhanced barrier precautions during a dressing change for a resident with an order for EBP and pressure ulcers on the left foot requiring dressings. During the observation, RN #64 and a visiting Administrator wore gowns and gloves, but the NA assisting with positioning only wore gloves. The NA leaned over the bed to help elevate the resident's left leg and foot, and her scrub top and pants contacted the bed linens while her bare arms rested on the resident's bare legs. In addition, two bedpans were observed in the bathroom between rooms C24 and C26, sitting on the commode and handrail without bags, and the RRRN confirmed they were unlabeled and not in a bag.
Failure to Monitor and Document Psychotropic Use and Behavioral Interventions
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to prevent unnecessary psychotropic medication use and to document behavioral monitoring and non-pharmacological interventions for a resident receiving antipsychotic medication. The facility’s policy on behavior management required staff to observe and monitor behavioral symptoms and document them in the medical record, and to implement individualized, person-centered, non-pharmacologic interventions. Resident #69 had physician orders for Risperdal (risperidone) since 2023 for schizophrenia with hallucinations and delusions, and a care plan focus for verbal behaviors associated with cognitive loss/dementia, including agitation, yelling, cursing, screaming, and attempts to hit and kick staff, as well as increased hallucinations of seeing snakes and rats. The care plan included interventions such as monitoring medications for side effects and response, evaluating triggers for behaviors, considering psych/behavioral health consultation, explaining care step-by-step, providing consistent caregivers and structured routines, removing the resident from the environment when needed, and maintaining a calm, quiet, well-lit environment. The resident’s Medication Administration Record contained a specific order initiated on 10/15/24 directing staff to assess daily on day and night shifts whether the resident was free from side effects of psychotherapeutic medications and, if not, to document side effects in progress notes. However, review of the MAR showed no documentation of behavioral monitoring or of non-pharmacological interventions for behaviors, and review of the rest of the electronic medical record likewise showed no evidence of such monitoring or interventions. During an interview, the DON confirmed that Resident #69’s records lacked documentation of behavioral monitoring and non-pharmaceutical interventions for behaviors. The survey also noted that the facility failed to ensure another resident was not overly medicated, resulting in drowsiness and restraint, and that this practice affected one of five residents reviewed for unnecessary medications during the survey.
Failure to Provide Ordered Double Entrée Portions at Meal Service
Penalty
Summary
The facility failed to provide a resident with the ordered double entrée portions at a meal. The resident had a physician’s order, written on 12/15/24, specifying double entrées with meals. During a noon meal observation on 04/20/2026, the resident was seated in the dining room with a nurse aide assisting. The resident’s tray ticket indicated he was to receive a double entrée, but his tray contained only one BBQ sandwich. While the nurse aide briefly left the table to obtain a clean spoon for another resident, the resident ate almost the entire BBQ sandwich, leaving only some bun, and picked BBQ meat that had fallen onto his shirt and ate it. When the nurse aide returned and was informed by the surveyor that the tray ticket called for double entrées, the nurse aide stated she did not know about the order and then indicated she would obtain another BBQ sandwich. No additional information was provided through the completion of the survey process. This deficiency involved a single resident (Resident #69) out of a facility census of 88 and was identified as a random opportunity for discovery during the survey. The record review confirmed the active physician’s order for double entrées, and the observation confirmed that the meal served did not comply with that order. Staff interview with the nurse aide further established that she was unaware of the double entrée requirement at the time the meal was served.
Room Change Without Resident Choice or Timely Notice
Penalty
Summary
The facility failed to ensure residents had a choice in room assignments and were notified in a timely manner before room changes were made. Resident #63, who had a BIMS score of 14, was moved from room A3 B to room D32 A. A review of the facility’s room moves for the prior month showed that eight residents had room changes listed as clinical need. During interview, Resident #63 stated she was not told the reason for the room change and said she would have stayed in her old room because she liked that hallway better. She also reported that when she went to her room, another resident was in her bed and staff then told her she was in a different room. The AD stated room changes were part of his responsibility, said he told her of the room change that morning, and acknowledged that more notice would be a good idea.
Incomplete and Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure complete and accurate MDS assessments for two residents. Resident #7’s MDS with ARD 03/18/26 coded a wound infection, but the medical record did not show a wound infection during the 7-day look-back period. During interview on 04/20/26, the LPN Clinical Reimbursement confirmed the MDS was incorrect and stated the diagnosis had been pulled from an older MDS that had correctly coded a wound infection. Resident #69’s quarterly MDS with ARD 03/02/26 indicated a hip fracture and other fracture, but no evidence of either fracture was found in the medical record during the 7-day look-back period. On 04/21/26, the Administrator confirmed the MDS was incorrect and stated the fracture diagnoses had been pulled from a previous MDS that had correctly coded hip fracture and other fracture.
Tube Feeding Not Administered as Ordered
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered in accordance with physician orders for Resident #59, who had an order for Isosource 1.5 at 60 mL/hr for 18 hours daily, scheduled to start at 12:00 PM and end at 6:00 AM. On 04/19/26, the resident was observed asleep in bed at 12:10 PM, 12:30 PM, 1:00 PM, and 1:45 PM with no tube feeding being administered. During interview, the DON confirmed the tube feeding was not hanging and should have started at 12:00 PM, and an LPN stated she forgot and missed her one-hour window, while also confirming she had already signed as if the feeding had been administered. Because the feeding had not been started as ordered, it would have needed to run until 8:00 AM on 04/20/26 to deliver the ordered volume. On 04/20/26 at 7:45 AM, no tube feed was hanging, and an LPN stated she had already stopped it for the day. The CRRN later confirmed the tube feeding did not appear to have hung for the ordered 18 hours and stated it would have to run for 18 hours for the resident to receive the ordered 1080 mL.
COVID-19 Vaccine Given Despite Representative Refusal
Penalty
Summary
The facility failed to administer COVID-19 vaccinations in accordance with professional standards of care after Resident #1's representative verbally declined the 2025-2026 COVID-19 vaccine for a resident who lacked capacity to make medical decisions. The facility policy stated that COVID-19 vaccination would be administered with patient or patient representative consent, and the resident's records included a form indicating no consent for the person to be vaccinated with the COVID-19 vaccine. Despite this documented refusal, the resident's MAR showed that the 2025-2026 COVID-19 vaccination was administered on 03/02/26. On 04/20/26 at 12:07 PM, the DON confirmed that Resident #1 received the vaccine even though the representative had declined it.
Failure to Maintain a Sanitary and Pest-Free Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not preventing or adequately addressing evidence of mice within the building. During the complaint investigation, an anonymous interview identified specific areas in the facility where mice droppings could be found, including behind residents’ furniture in two resident rooms. A second anonymous interview corroborated this information, confirming that mouse droppings had been seen behind residents’ furniture in those two rooms. On a subsequent observation, the surveyor directly observed mice droppings on the floor near the outer wall to the left in the Activities Director’s office on B Hall. The Regional Administrator verified the presence of the droppings during the surveyor’s observation, and during the exit interview, the Administrator, Clinical Lead, and Market Resource Clinician acknowledged these findings. The deficiency had the potential to affect more than an isolated number of residents in a facility with a census of 89, as the unsanitary condition involved multiple locations within the building, including resident rooms and a staff office area.
Failure to Maintain Proper Refrigerator Temperatures in Rehab Pantry
Penalty
Summary
The facility failed to store food in accordance with professional standards by not maintaining proper refrigerator temperatures in the Rehab pantry room. Specifically, the refrigerator was documented as having temperatures above 41 degrees Fahrenheit during several PM temperature checks, with no documentation of corrective action on multiple dates. Additionally, there was a missing AM temperature check documentation for one date. These findings were confirmed through observation, document review, and interviews with the DON and the facility Administrator.
Unsanitary Conditions in Rehab Pantry Room
Penalty
Summary
Surveyors observed several gnats present on the left-hand side of the sink countertop in the Rehab pantry room, as well as exposed damp wood on the same side of the countertop. These unsanitary conditions were directly noted during an inspection and were verified by both the facility's Maintenance Director and the Administrator at the time of discovery. The deficiency was identified as having the potential to affect more than an isolated number of residents, with a facility census of 84 at the time of the survey. No information was provided regarding specific residents' medical histories or their conditions at the time of the deficiency.
Failure to Enforce Mask Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as required, specifically during a COVID-19 outbreak. Upon entry, surveyors observed a sign at the main entrance indicating an active COVID outbreak, which was confirmed by the Administrator. During the survey, two nurse aides were seen on a resident hall with their N-95 masks pulled down under their chins, not covering their faces as required. Facility policy, consistent with CDC guidance, mandates that staff wear well-fitting masks, including N-95 respirators, during an active COVID-19 outbreak. The Administrator confirmed that all staff were expected to wear N-95 respirators when there was an active case in the building and acknowledged that the two staff members were not in compliance with this policy while on the resident hall. These actions and observations demonstrate a failure to follow established infection control protocols, potentially affecting more than an isolated number of residents, with a facility census of 88 at the time.
Failure to Ensure Resident Dignity and Privacy During 1:1 Monitoring
Penalty
Summary
A resident was placed on continuous one-on-one (1:1) monitoring following an incident where the resident was reported to have trashed his room, kicked a heater, let water run in the sink, cursed, and thrown razors around. The 1:1 monitoring required the resident's door to remain open at all times, including during toileting, bathing, and changing clothes. The resident expressed embarrassment and distress about the lack of privacy, stating that staff would not allow the door to be closed even during personal care activities. The resident also reported feeling disrespected by staff, who spoke to him in a condescending manner and continued to engage him in conversation against his wishes. Staff interviews confirmed that the door was kept open for monitoring, and the administrator acknowledged that staff were afraid to be alone with the resident due to his behaviors. The administrator stated that a privacy curtain had been offered but declined by the resident, and was uncertain about alternative solutions. Review of the resident's documented behaviors during the monitoring period showed only three incidents of yelling or cursing, each resolving within 15 minutes without further intervention. The facility failed to ensure the resident's right to dignity and privacy during personal care, as required by regulations.
Failure to Report Suspected Crimes and Changes in Condition
Penalty
Summary
The facility failed to report two separate changes in condition for a resident involving behaviors that led staff to contact local law enforcement due to reasonable suspicion of a crime. On two occasions, staff called the police: first, when the resident exhibited disruptive behaviors such as trashing his room, kicking a heater, letting water run in an attempt to flood the room, cursing, and throwing razors. The facility physician recommended a psychiatric evaluation, but the resident, who had decision-making capacity, refused to leave. The second incident involved the resident being on 1:1 observation, wanting to keep his door shut, and reacting with screaming, cursing, and slamming the door, which reportedly caused harm to a staff member, though no injuries were documented. Despite these incidents and the involvement of law enforcement, the facility did not report the changes in condition or the reasonable suspicion of a crime to the appropriate State agencies as required. Interviews with the resident and the Administrator confirmed the events and the lack of reporting. The Administrator acknowledged that police reports were made but had not been received by the facility, and stated that the incidents were not viewed as reportable events at the time.
Failure to Obtain Physician Order for One-on-One Observation
Penalty
Summary
The facility failed to obtain a physician's order before placing a resident on one-on-one observation status following an incident involving disruptive behavior, including damaging property and attempting to flood the room. Despite the physician recommending that the resident be sent to an acute care facility for psychiatric evaluation, the resident, who had decision-making capacity, refused the transfer. The facility did not update the physician regarding the resident's refusal to go out for evaluation. Record review confirmed that there was no physician's order in place for the one-on-one observation, and this was verified by the Administrator during the investigation.
Incomplete Documentation on POST Form
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident. During a record review, it was found that the West Virginia Physician Order for Scope of Treatment (POST) form for this resident was missing both the preparer's signature and the date. This omission was identified during the survey and confirmed through staff interview.
Unattended Medication Cart and Unsafe Storage of Razors
Penalty
Summary
A deficiency was identified when a medication cart was observed unlocked and unattended in a hallway between resident rooms. The LPN responsible for the cart was seen exiting a resident room with the door closed, leaving the cart accessible and unsecured. Later, the same LPN retrieved medications for another resident and again left the cart unattended and unlocked. The Director of Nursing confirmed that medication carts are required to be locked when not attended. Additionally, a resident's representative reported that the resident had razors in her bedside table. Upon inspection, the Director of Nursing found two razors in the resident's room, which were accessible to others. Facility policy requires that razors not be kept in resident rooms unless secured in locked boxes and only for residents deemed safe to use them independently. The resident in question had a BIMS score indicating mild cognitive impairment and lacked capacity to make her own medical decisions.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews for all residents, as required by facility policy. Specifically, for three of five residents reviewed for unnecessary medications, there was either missing documentation of the pharmacist's monthly review or a lack of evidence that the physician addressed the pharmacist's recommendations. For one resident with a recent fall, the pharmacist recommended evaluating certain medications due to their potential to contribute to falls, but there was no documentation that the physician reviewed or responded to these recommendations. The resident's medication orders showed only a partial change, with no indication of physician agreement or rationale for disagreement as required by policy. Additionally, for two other residents, there was no evidence of pharmacy reviews for several months, and staff confirmed that the required monthly reviews were not available in the medical records. One of these residents had multiple diagnoses, including dementia with agitation, schizophrenia, and anxiety disorder, and was prescribed several psychotropic medications. The absence of documented monthly medication regimen reviews and physician follow-up on pharmacy recommendations was confirmed by staff interviews and record reviews.
Expired Medications and Undated Insulin Pens Found During Medication Storage Review
Penalty
Summary
Surveyors observed that the facility failed to store and label medications in accordance with professional standards. During an inspection of the D hallway medication cart, multiple multi-dose medication bottles, including vitamin C tablets, senna syrup, loratadine, and guaifenesin, were found to be past their manufacturer's expiration dates. These medications had been opened and continued to be stored and available for use despite being expired, as confirmed by an LPN present during the inspection. Additionally, three insulin pens for different residents were found in the medication cart without documentation of the date they were first accessed. Proper practice requires insulin pens to be dated upon first use to ensure they are discarded after 28 days, but this was not done for the pens observed. The LPN confirmed that these insulin pens had not been dated when first accessed, and the pens had been delivered from the pharmacy on various dates prior to the inspection.
Failure to Use Proper Utensils for Menu Portioning
Penalty
Summary
During a dining observation in the Alzheimer's unit, the Activity Director was seen preparing and serving lunch plates for residents using inappropriate utensils, such as a mouth-sized fork for turkey, a spatula for stuffing, and a ladle for peas. The Activity Director stated that the correct portioning utensils were not available because the kitchen had not sent them. The administrator confirmed that the appropriate utensils for portion sizes were not being used. A review of the corporate recipe specified that three ounces of turkey, a half cup of dressing, and a half cup of peas were to be served, but the lack of proper utensils prevented accurate portioning. Facility policy requires menus to meet nutritional needs and be followed according to established guidelines.
Deficiencies in Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
Surveyors observed several deficiencies in food storage and handling practices during their inspection. In the Alzheimer's unit, a refrigerator contained 14 servings of apple crisp on a tray without any date labeling. When interviewed, an LPN was unable to confirm when the apple crisp had been placed in the refrigerator and acknowledged the absence of a date. Facility policy requires that prepared foods be labeled and dated with the product name, date opened, and use-by date, which was not followed in this instance. In the main kitchen, four boxes were found stored directly on the floor of the walk-in freezer, contrary to facility policy that mandates all items be stored at least six inches off the floor. A kitchen aide confirmed that the chef had left the boxes on the floor. Additionally, a white blanket was found behind the kitchen door in the food service area, which a kitchen aide explained was used to absorb water seeping in from a drain during rain. These findings indicate failures to adhere to professional standards for food storage, preparation, and environmental cleanliness as outlined in facility policies.
Staff Served Food Without Required Food Handler Certification
Penalty
Summary
During a dining observation in the Alzheimer's unit, the Activity Director (AD) was seen preparing lunch plates for residents in the kitchen area. When asked by the surveyor, the AD confirmed that she did not possess a food handler's card. A review of the Kanawha County Health Department requirements indicated that any individual who handles, prepares, serves, sells, or gives away food for human consumption must obtain food handler training within 30 days of starting work. The facility administrator also confirmed that the AD did not have the required food handler's card as mandated by county regulations. This failure to ensure that staff serving food had the appropriate food handler certification was identified through record review, staff interview, and observation, and was determined to be a deficiency in compliance with Federal, State, and local laws and regulations.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. One resident was admitted with an indwelling urinary catheter, which was ordered to be removed, but skilled nursing evaluations continued to inaccurately document the presence of the catheter for several days after its removal. This inaccuracy was confirmed by the Clinical Resource Nurse. Another resident's Physician Order for Scope of Treatment (POST) form only had a verbal approval from the resident's medical power of attorney, obtained over the phone, despite the representative visiting the facility frequently. The Social Worker confirmed that a physical signature should have been obtained by this time. These findings demonstrate incomplete and inaccurate documentation in the residents' medical records, specifically regarding genitourinary status and required signatures on treatment orders.
Failure to Implement Enhanced Barrier Precautions for Residents with PEG Tubes
Penalty
Summary
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own policies and professional standards of care. The facility's policy required EBP for residents with indwelling medical devices, such as percutaneous endoscopic gastrostomy (PEG) tubes, and specified that appropriate signage should be posted on the resident's room door. During observations, two residents with PEG tubes for enteral nutrition did not have EBP signs posted on or near their room doors, despite being care planned for EBP. In both cases, personal protective equipment (PPE) was available, but the required signage was missing at the time of initial observation. For one resident, the absence of the EBP sign was noted even though the care plan indicated EBP had been in place for several months. The other resident, who was totally dependent on staff for enteral nutrition and PEG tube care, also lacked the required signage. These findings were confirmed by facility nursing staff, who acknowledged that EBP signs should have been posted due to the presence of PEG tubes. The lack of proper signage represented a failure to fully implement the facility's infection prevention and control program as outlined in its policies.
Stove in Disrepair with Improvised Covers in Alzheimer's Unit
Penalty
Summary
During an initial tour of the Alzheimer's unit, surveyors observed an electric cooking stove in the kitchen area with only one of four stove eyes in place, while the remaining three were missing and replaced with a glass serving plate. An LPN confirmed that the stove had been in this condition for some time and stated that the stove was not used by staff, but was occasionally used by the activities department. The administrator also confirmed the absence of the stove eyes and the use of glass plates to cover the holes. A review of the facility's policy indicated that all equipment should be maintained in good working condition to ensure safe and sanitary food preparation and service.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Surveyors observed the presence of gnats in the bathrooms of two different resident rooms and in the administrative conference room during the initial facility tour. The observations were made in Room #A01 at 11:30 AM and Room #B11 at 12:30 AM. These findings indicate that the facility did not maintain an effective pest control program to prevent or address the presence of pests within the physical environment. Staff interviews confirmed the observations, with the facility administrator acknowledging the issue and indicating awareness of the pest presence.
Failure to Update PASARR with Accurate Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) accurately reflected the resident's preadmission diagnoses of schizophrenia and anxiety disorder. Record review showed that the PASARR submitted when the resident was transferred from another facility did not include these diagnoses, despite the resident having active orders for medications to treat schizophrenia and anxiety. During an interview, the social worker confirmed that the PASARR was missing the relevant diagnoses and acknowledged that it should have been re-submitted, but was unable to provide an updated PASARR document.
Failure to Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of anticoagulant medication for one resident who had been prescribed apixaban (Eliquis) for atrial fibrillation. Although the resident had been receiving this medication since 07/19/24, which carries a risk of bleeding as a side effect, the resident's care plan did not include a focus or interventions related to monitoring for signs and symptoms of bleeding, such as bloody stool or urine, nosebleeds, bruising, or changes in mental status or vital signs. This omission was confirmed by the Clinical Resource Nurse during staff interview and record review.
Failure to Provide Consistent Oral Care to Dependent Resident
Penalty
Summary
The facility failed to provide consistent oral care to a dependent resident who required assistance with activities of daily living due to limited mobility and dependence for transfer. The resident, who had mild cognitive impairment and lacked capacity to make her own medical decisions, reported that her teeth were not being brushed twice daily as she wished. This concern was echoed by her family member, who stated that oral care had been discussed at a recent care plan meeting but was still not being performed as required. A grievance was filed regarding the lack of oral care, and documentation in the nurse aide task report showed frequent omissions in both morning and evening oral care entries for the resident over a multi-day period. Review of the resident's care plan indicated a need for staff to encourage and assist with oral care, yet the medical records revealed inconsistent documentation and several days with no evidence that oral care was provided. Interviews with the resident and review of records confirmed that oral care was not consistently performed or documented twice daily, as required for the resident's condition and care plan.
Failure to Follow Physician Orders for Weights and Splint Application
Penalty
Summary
The facility failed to follow physician's orders for two residents. For one resident with a recent order for weekly weights due to weight loss, the facility did not obtain the required weight until six days after the order was written. This delay was confirmed by both the Director of Nursing and the Clinical Resource Nurse, who acknowledged that the weight should have been obtained promptly after the order was placed. For another resident with a medical diagnosis of right hand contractures, there was a physician's order for a resting hand splint to be applied to the right hand for four hours daily while out of bed, with monitoring for skin integrity. Review of the Treatment Administration Record showed multiple dates in which the splint was not applied as ordered. Direct observation and resident interview confirmed that the splint was not in use during several checks, and the resident stated that staff did not put it on her. These findings were confirmed with facility nursing leadership.
Failure to Accurately Document Meal Intake and Monitor Nutrition Status
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutrition to prevent weight loss by not documenting accurate meal intakes. For one resident reviewed for nutrition, there was a significant weight loss of 22.73% over two months, with weights dropping from 140.8 lbs to 108.8 lbs. The resident's ideal body weight was noted as 125.1 lbs. Review of the resident's meal intake records showed that out of 318 possible meals, 45 were not recorded, and 75 of the 273 recorded meals indicated the resident consumed 25% or less of the meal. Staff interviews revealed concerns that the resident's admission weight may have been inaccurately recorded by using a hospital-reported weight rather than obtaining an actual weight upon admission. Both the Clinical Resource Nurse and the Registered Dietician acknowledged this issue, and the administrator confirmed that proper meal intake documentation was lacking, which prevented an accurate assessment of the cause of the resident's weight loss.
Failure to Document Pain Assessment Prior to PRN Medication Administration
Penalty
Summary
The facility failed to monitor and treat pain in accordance with professional standards of practice for one resident. According to the facility's pain management policy, reasons for administering PRN pain medication must be documented. A review of a resident's physician's orders showed an as-needed order for acetaminophen for pain. The Medication Administration Record indicated the resident received acetaminophen once, and while the effectiveness of the medication was documented, there was no documentation of the location or severity of the resident's pain on the MAR or in the nurse's progress notes. The Clinical Resource Nurse confirmed that a pain assessment had not been documented prior to the administration of the PRN medication.
Failure to Provide Resident with Preferred and Prescribed Meal Options
Penalty
Summary
The facility failed to meet a resident's special dietary requirements and preferences during a meal service. Observation showed that a resident was served turkey, stuffing, and peas, despite their meal ticket specifying a chicken sandwich, lettuce and tomato, chef salad, and a baked potato. The resident expressed that they were supposed to receive a salad and did not always like the food provided, but tried to eat it regardless. A dietary aide confirmed that the specified chicken sandwich was unavailable and that a salad and baked potato were being provided as substitutes. Review of the resident's records indicated that the resident was cognitively intact at the time of the incident.
Medication Dosage Error in Comfort Care Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct dosage of medication as prescribed by the physician assistant, leading to an immediate jeopardy situation. The resident, who had multiple diagnoses including Sick Sinus Syndrome, Diabetes Type 2, Dementia, and Kidney Failure, was on comfort care and had an order for Morphine Sulfate Oral Solution. However, the order was incorrectly entered as 2.5 ml instead of the intended 2.5 mg, resulting in the resident receiving a larger dose than prescribed. The error occurred when the licensed practical nurse administered the medication according to the incorrect order on the Medication Administration Record (MAR). The nurse did not question the order, believing it was justified due to the resident's comfort care status. The physician assistant later realized the error and corrected the order, but not before the resident had already received two doses of the incorrect amount. The Director of Nursing was unaware of the situation until it was brought to her attention by the surveyor. The error was identified during a review of the resident's records and staff interviews, highlighting a breakdown in communication and verification processes within the facility. The incident affected not only the resident involved but also had the potential to impact all residents receiving controlled substances or medications at the facility.
Facility Environment Deficiency
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations and staff interviews. During a walkthrough with the Maintenance Director and Maintenance Assistant, issues such as black scuff marks, peeling paint, and evidence of spiders were found in various areas of the facility, including several doors on D hall and the fine dining area in the D wing. The Maintenance Director and Assistant acknowledged awareness of these issues, stating they were new to the facility and prioritizing safety concerns first.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that three residents were seen by a physician at the required intervals. Specifically, the facility did not comply with the regulation that mandates a physician visit at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Resident #28 was not seen by a physician every 60 days, with gaps in visits noted between specific dates. Similarly, Resident #72 and Resident #44 also experienced lapses in the required physician visits. Although physician assistants had seen the residents, these visits did not alternate with physician visits as required. During an interview, the administrator and director of nursing confirmed the deficiency, acknowledging that the physician had not seen the residents every 60 days as mandated.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for several residents, as observed in multiple rooms. In Room B10, the trim underneath the heating and cooling unit was detached and lying on the floor, exposing the wall behind it. A resident mentioned that the issue had been present for some time without being addressed. In Room B14, a glove was found on the floor beside the trash can, and a large piece of clear plastic along with multiple pieces of paper were discovered under a resident's bed. The Housekeeping Manager in Training acknowledged these issues. In Room C26, a medical glove and other debris were found on the floor, along with a trail of a brown substance leading from a resident's bed to the bathroom, where it was also present on the toilet seat. Torn toilet paper was scattered on the bathroom floor, and the shower was running with plastic cups inside. The Director of Nursing acknowledged these findings. In Room D31, medical gloves and bottles of lotion were found on the floor, and small black grains, identified as mouse droppings, were discovered in a resident's wardrobe. The Business Office Manager and Maintenance Supervisor acknowledged these issues.
Inadequate Nutritional Care and Documentation for Resident
Penalty
Summary
The facility failed to provide adequate nutritional care for a resident, identified as Resident #2, who experienced significant weight loss over a period of three and six months. The resident had a medical history of an eating disorder, feeding difficulties, and a recent diagnosis of Amyotrophic Lateral Sclerosis (ALS). Despite being on a regular diet with large portions and requiring feeding assistance, the resident's weight dropped from 190.2 pounds to 166.4 pounds, indicating a 12.1% weight loss over six months, which is considered significant. The Registered Dietitian (RD) responsible for assessing the resident's nutritional status acknowledged insufficient documentation of meal intakes, which hindered accurate assessment. The RD noted meal intakes ranging from 25% to 100% but admitted that the documentation was inadequate to determine the resident's nutritional needs accurately. The RD did not address this issue with the facility's administration or other staff, which contributed to the deficiency in nutritional care. A review of the facility's Follow Up Questions Report revealed that out of 91 opportunities to document meal intakes, only 15 were recorded. This lack of documentation was confirmed by the Director of Nursing (DON), who agreed that there was not enough information to accurately assess the resident's meal intake for nutritional status assessments. The deficiency was identified as a failure to maintain acceptable parameters of nutrition for the resident, as required by regulatory standards.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in several rooms and with equipment, as observed during a survey. In Room #D32, trash and food were found on the floor under the beds and throughout the room. A registered nurse acknowledged the issue and indicated it would be addressed. In Room #D37, two nightstands were observed to be dirty and stained, which was confirmed by a licensed practical nurse. Additionally, Room #D40 had a soiled blanket with a dry, brown substance on the bed, which was also confirmed by a licensed practical nurse. Furthermore, the facility's sit-to-stand lifts were found to be soiled with dirt and debris on the platform where residents place their feet. During an interview, the nursing home administrator and the director of nursing expressed uncertainty about the responsibility for cleaning the lifts, although the facility's infection control policies require that multi-function equipment be cleaned and disinfected between residents. The policy also states that items should be bagged or labeled after cleaning to indicate readiness for the next use.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications within the physician-ordered time frames for three residents during the month of December 2023. This deficiency was identified during a complaint survey, where it was found that medications for Resident #2, Resident #27, and Resident #46 were consistently administered late. The delays ranged from over an hour to more than eight hours past the scheduled administration times, indicating a significant deviation from the prescribed medication schedules. Resident #27 experienced multiple instances of late medication administration, including a five-hour delay in receiving insulin and over two-hour delays for several other medications such as cyanocobalamin, duloxetine, and warfarin. Similarly, Resident #2 had numerous medications administered late, with delays ranging from over an hour to nearly five hours. These included critical medications like Eliquis, Buspar, and various ophthalmic solutions. Resident #46 also faced significant delays, with medications such as gabapentin, insulin, and hydralazine being administered up to eight hours late. The Director of Nursing confirmed these findings during interviews, acknowledging the failure to adhere to the physician's orders. The report highlights the facility's inability to maintain timely medication administration, which is crucial for the residents' health and well-being. The consistent pattern of late medication administration across multiple residents suggests systemic issues within the facility's medication management processes.
Failure to Implement Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to implement the care plan for a resident identified as being at risk for falls due to cognitive loss, lack of safety awareness, impaired mobility, and a history of falls. The care plan, updated on 10/22/23, included a goal to prevent falls with major injury requiring hospitalization. However, during an observation on 12/18/23, it was noted that the resident was sleeping in their room without a radio within reach on the left side of the bed, as specified in the care plan. On 12/19/23, the Director of Nursing confirmed in an interview that the radio, which was part of the care plan, had been taken home by the family.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care according to professional standards of practice, as observed in multiple instances involving residents. Resident #2's nebulizer mask was found on the nightstand without being stored in a respiratory bag, which was confirmed by LPN #13 and later by the Director of Nursing (DON) and the Administrator. Similarly, Resident #76's nebulizer mask was also observed on the nightstand without proper storage, and this was again confirmed by LPN #13 and the facility's leadership. Additionally, Resident #28's nasal cannula was found laying directly on the floor, which was acknowledged by LPN #13 as inappropriate. Resident #1's nebulizer mask was similarly found on the nightstand without being in a respiratory bag, with RN #47 confirming the improper storage. These observations indicate a pattern of non-compliance with proper respiratory equipment storage protocols, as confirmed by the nursing staff and facility administration.
Deficiencies in Controlled Substance Management and Documentation
Penalty
Summary
The facility failed to establish a system to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. During an observation of the medication cart for the A and D halls, it was found that a lorazepam tablet had been removed and then taped back into the medication card for a resident. The LPN responsible for the cart stated that she did not tape the pill back in, and the Director of Nursing (DON) confirmed that this was not an acceptable practice. Similarly, on the medication cart for Mary's Garden, a clonazepam tablet was found taped back into the medication card, which was also not noticed by the LPN responsible for that cart. The DON confirmed that this practice was unacceptable. Additionally, for another resident, there were discrepancies in the documentation of tramadol administration. The controlled substance log indicated that tramadol was signed out on three separate occasions, but it was not documented as administered on the Medication Administration Record (MAR). The DON confirmed these findings and acknowledged the issue. These deficiencies have the potential to affect more than a limited number of residents, as indicated by the facility's census of 83 residents.
Infection Control Deficiencies in Linen and Equipment Storage
Penalty
Summary
The facility failed to maintain appropriate infection control standards in several rooms, as observed during a survey. In Room D38, soiled linens were found in two clear plastic bags that were left open and untied on the floor by the bathroom. A resident confirmed that these linens were from a recent cleaning. Similarly, in Room D32, soiled linens were observed in two plastic bags on the floor by the door. Both instances were confirmed by an LPN and the Director of Nursing (DON), who acknowledged that the linens should have been tied and removed from the rooms. Additional deficiencies were noted in other rooms. In Room C26, a used wash basin was found on the floor behind the commode, and in Room C25, a dirty urinal with a dried brown substance was hanging on the safety rail in the bathroom. The DON confirmed that the substance was related to a resident's medical condition. In Room D31, a used bed pan was observed on the floor behind the commode. These items were not stored correctly, as confirmed by the nursing staff and the DON, who were notified of these issues during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 70 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marmet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Charleston Healthcare Center | 6.5 mi | ★★★★★ | 14 | 0 |
| Glasgow Hills Of Journey | 7.7 mi | ★★★★★ | 3 | 0 |
| Complete Care At Oak Ridge Llc | 8.8 mi | ★★★★★ | 0 | 0 |
| Thomas Hospitals Skilled Nursing Unit | 9.1 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Acres | 9.8 mi | ★★★★★ | 5 | 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.