Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morgantown Healthcare Center during CMS and state inspections, most recent first.
Inadequate supervision and poorly documented behavior interventions allowed a resident with repeated agitation, wandering, and room-entry behaviors to enter another resident’s room and engage in a struggle over an iPad. The other resident fell and sustained a subarachnoid hemorrhage and subdural hematoma. Staff and the DON reported that redirection was often ineffective, behavior monitoring was not in place, and the care plan had not been meaningfully updated to address resident-to-resident behaviors.
Meal service did not follow posted menus and tray cards for several residents. A resident did not receive milk, two residents did not receive poultry gravy, one resident on a pureed diet was served a regular roll instead of the ordered item, and another resident’s cereal tray was missing a serving and milk. An LPN, nurse aide, and account manager confirmed the missing or incorrect items during the dining observation.
A facility failed to provide ordered adaptive eating equipment and utensils at mealtimes for multiple residents. Residents were observed without Dycem, a scoop plate, or the ordered Kennedy cup despite tray cards and physician orders indicating these items, and staff confirmed the equipment was not present or had never been provided. One resident was also seen drinking from a regular coffee cup instead of the ordered special cup.
The facility failed to timely report a resident-to-resident abuse allegation involving a resident who sustained a scalp injury and intracranial bleeding after a struggle over an iPad, and the initial report was not sent within the required 2-hour timeframe. The facility also failed to submit a required 5-day follow-up for a separate resident-to-resident abuse allegation in which one resident grabbed another resident’s arm, leaving fingernail marks; the DON could not locate the report, and the State Agency confirmed it was not submitted.
Failure to Update Behavior and Activity Care Plan: A resident with cognitive impairment and documented physical aggression toward other residents had additional behavior episodes that were not reflected in the care plan. Staff confirmed the resident could not fully comprehend behavior education, there were no resident-to-resident interventions on the plan of care, and activity interventions had not been updated despite the resident not attending groups, needing limited-duration activities, and receiving no one-to-one activities.
A resident who needed ADL assistance was left overnight in street clothes and a soiled brief after night staff misread the care plan and assumed that not disturbing sleep meant no bedtime hygiene, clothing change, or evening toileting was needed. The resident and morning staff reported she was found wet and still dressed in the prior day’s clothing, while the CNA claimed care had been provided.
Failure to provide ongoing activities for a resident with behavioral needs. A resident who was incapacitated, wandered the halls, and had repeated agitation and resident-to-resident incidents was not given consistent group or individual activities aligned with stated interests such as music and church. The activity log showed many missed activity days, staff said the resident did not attend group activities often, and the facility did not provide individual one-on-one activities.
A resident who suffered a traumatic resident-to-resident assault with a head injury and intracranial bleeding continued to report fear that the other resident would enter her room again. The record showed the other resident had repeated room-entry and agitation issues, but there was no documentation of psychosocial monitoring for the affected resident after the incident, despite later anxiety and agitation noted in the chart.
A resident with a dysphagia puree diet order was served a regular consistency roll at lunch. An NA buttered the roll and gave it to the resident in the dining room until a surveyor intervened and had it removed; the NA acknowledged the resident should not have received it.
Two residents were moved from private to semi-private rooms or faced additional charges without receiving written notice, explanation of the policy change, or the opportunity to visit their new rooms. Staff and family interviews confirmed that only verbal notifications were given, and residents experienced distress and inconvenience as a result.
Dietary staff, including a manager and an aide, worked with expired State Food Safety Certificates, with the aide continuing to work multiple shifts without valid training before resigning. The lapse in maintaining current food safety credentials was confirmed by facility leadership and had the potential to impact a significant number of residents.
Surveyors found that food items in multiple pantries and the kitchen were not properly labeled or dated, with some open containers and unsealed items lacking required information. Additionally, refrigerator temperatures were found to be outside recommended ranges, and these issues were confirmed by nursing and food service staff.
The facility did not maintain proper documentation or protocols for its water management program, including the absence of a detailed building water system description and Legionella control measures. This lapse in infection prevention and control had the potential to impact all residents in the facility.
The facility did not update a resident's care plan after discontinuing an anticoagulant, leaving outdated interventions in place, and failed to provide clear guidance in another resident's care plan regarding the required level of assistance for ADLs. Staff interviews confirmed the lack of clarity and appropriate updates.
A resident with significant medical conditions, who was unable to get out of bed, was not provided with activities tailored to their interests or needs. Despite a care plan listing various preferred activities and a requirement for 1:1 engagement, the resident spent days in bed with only TV for stimulation and had no documented participation in other activities during the review period.
Two residents experienced deficiencies when staff failed to ensure medication orders matched the pharmacy supply and did not notify the physician about the discrepancy, and when a Speech Therapy evaluation ordered for a resident with increased coughing was not completed in a timely manner. These lapses resulted in delays in care and failure to follow physician orders.
A resident was observed smoking multiple times in a non-designated area outside the facility's front entrance, where no ash can, fire blanket, or fire extinguisher was present, despite a 'No Smoking' sign. Facility leadership acknowledged the resident was not following the smoking policy and that a designated area had been provided but was not used.
A resident with a tracheostomy and complex medical needs did not receive the physician-ordered oxygen flow rate, as the oxygen concentrator was repeatedly set below the prescribed 5 LPM during multiple observations. This discrepancy was confirmed by record review and staff interview, indicating a failure to ensure safe and appropriate respiratory care.
A resident's POST form was found to be incomplete, lacking the required Medical Power of Attorney (MPOA) signature and instead containing only a verbal signature. The DON confirmed the form was not properly completed as mandated.
A facility did not conduct a thorough investigation into an allegation that a staff member physically abused a resident by defecating on them and drawing with feces. Although the incident was reported and the staff member no longer works at the facility, the investigation lacked witness statements from employees who may have had knowledge of the event, and there was no documentation from all staff present at the time.
Inadequate supervision allowed resident-to-resident assault with serious injury
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and failed to provide adequate supervision when Resident #42, who had a documented history of agitation, wandering, entering other residents’ rooms, and physical aggression, was able to access Resident #65’s room and become involved in a resident-to-resident altercation. The incident resulted in Resident #65 sustaining a subarachnoid hemorrhage and subdural hematoma after being knocked down during a struggle over her iPad. The facility substantiated resident-to-resident physical abuse in its incident report, and Resident #42 was placed on one-on-one supervision after the event. Resident #42’s record showed repeated behavioral concerns before the incident, including being agitated, combative, exit-seeking, entering other residents’ rooms, and causing or being involved in multiple resident-to-resident conflicts. Clinical Psychological Services recommended consistent redirection, frequent re-orientation, a structured environment, limited overstimulation, and monitoring for further agitation or interpersonal conflicts. Progress notes also documented that redirection was often ineffective, that the resident wandered throughout the facility, and that one-on-one supervision had limited success. Surveyor observation later found the resident wandering in multiple halls and being redirected by staff. Review of the care plan and staff interviews showed that resident-to-resident behavior interventions were not adequately reflected or updated. The RN/MDS Coordinator stated the only care plan update for behaviors was a wander guard and that no intervention had been edited or revised since 2024. The Social Worker confirmed there were no resident-to-resident interventions on the care plan and that the listed behavior interventions were limited to informing family and the MD and educating the resident, despite acknowledging the resident would be difficult to educate. The DON also stated there was no resident-to-resident behavior monitoring chart for the resident, and staff described relying on informal redirection such as snacks, coffee, books, activities, and moving the resident away when she entered other residents’ rooms.
Meal trays did not match posted menus and tray cards
Penalty
Summary
The facility failed to ensure menus were prepared in advance and followed to meet residents’ nutritional needs. During a dining observation, the posted menu for Monday listed Chicken Stir Fry with vegetables, broccoli florets, steamed rice, a buttered dinner roll, and pear crisp, and the dysphagia advanced menu extension also included poultry gravy. The facility’s meal distribution policy stated that dining services staff, under the supervision of the licensed nurse, would assemble meals in accordance with the individual meal card and present them for delivery to the resident or care staff. Several residents did not receive items listed on their tray cards or menu extensions. One resident did not receive 8 ounces of milk and stated she never gets milk at supper; an LPN confirmed the milk and cup were not provided. Another resident did not receive poultry gravy or the two rolls listed on the tray card, and a nurse aide confirmed the omissions. A resident on a pureed diet received a regular buttered dinner roll instead of the pureed roll listed on the tray card, and the surveyor intervened before the resident ate it. Two other residents also did not receive poultry gravy as listed, and one resident’s cereal tray was missing the second serving and milk. Staff members confirmed the tray card and meal discrepancies as they were observed.
Adaptive Eating Equipment Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that adaptive eating equipment and utensils were provided at mealtimes as ordered by the physician and as identified on residents’ tray cards and care plans. The facility policy stated that appropriate assistive devices and utensils would be provided as indicated in physician orders and the individualized plan of care. During observations and interviews, Resident #5 was seen at lunch without Dycem under the plate, although the tray card indicated Dycem and the resident’s order stated Dycem with meals; the resident said she gets Dycem sometimes, and the SLP confirmed none was present. Resident #62 was also observed at lunch without Dycem under the plate, despite the tray card and order calling for a Dycem mat and scoop plate with all meals; the nurse aide confirmed there was no Dycem and stated the plate usually has a ring around it, but this one did not. Resident #53 was observed without the ordered blue Kennedy cup and instead had a two-handled cup with a spouted lid. The LPN confirmed the resident did not have the ordered cup and stated the resident had never had one. Another resident was reported to usually not receive the two-handled cup with lid printed on the tray card; the LPN confirmed the resident did not receive the cup, stated she had never seen it in three years, and the resident said she never gets a special cup. The resident was observed drinking from a regular coffee cup during the dinner meal.
Failure to Timely Report Resident-to-Resident Abuse and Submit Required Follow-Up
Penalty
Summary
The facility failed to ensure an allegation of resident-to-resident abuse was reported immediately, and not later than two hours after the allegation when serious bodily injury was involved, for a resident-to-resident incident involving Resident #65 and another resident. According to the incident report, staff found the other resident in Resident #65’s room holding the victim’s iPad, and staff believed the resident was rummaging through the victim’s belongings. During a struggle to take the iPad back, Resident #65 lost balance, struck the occipital scalp, and began bleeding; the resident also complained of nausea, was positioned on her side, had a large emesis, and was transferred to the Emergency Department. The trauma history and physical report documented acute medial right frontal lobe multifocal subarachnoid hemorrhage and a parafalcine and right tentorium subdural hematoma measuring up to 5 mm. The initial report to OHFLAC and the Ombudsman was sent the next day, outside the required two-hour timeframe, and the DON confirmed it was not reported within two hours. The facility also failed to submit a required five-day follow-up report for another resident-to-resident abuse allegation involving Resident #3 and Resident #115. The initial allegation report stated Resident #3 grabbed Resident #115’s right arm, leaving fingernail marks, and staff separated the residents immediately. The investigation included resident and staff interviews and determined Resident #3 was upset because Resident #115’s chair was squeaking and driving him crazy. However, no five-day report was found in the file provided to the surveyor, and the DON stated he could not locate one. The State Agency later confirmed that a five-day follow-up was not submitted to OHFLAC.
Failure to Update Behavior and Activity Care Plan
Penalty
Summary
The facility failed to revise Resident #42’s comprehensive care plan for behavior management interventions and activities after additional behavioral episodes were documented. The care plan listed episodes of physical aggression toward other residents, but new incidents on 02/18/26, 02/21/26, and 06/20/26 were not added to the plan. The interventions on the care plan included educating the resident about the potential harm of pushing or attempting to push other residents and instructing the resident to request staff assistance rather than pushing others. Social Worker #50 confirmed the resident would have difficulty comprehending the education because of cognitive status, and the resident was described as incapacitated with no BIMS completed because the resident hardly/never understood. On 07/28/26, Social Worker #50 confirmed there were no resident-to-resident interventions on the plan of care. On 07/29/26, Activities Leader #117 reported the resident had family one-to-one time, did not go to group activities, liked music and church, and was not provided one-to-one activities by the facility. The activities leader also stated the resident was encouraged to attend activities, liked to walk the halls, was given packets of images for self-directed activities, and was not able to attend activities and groups for long periods of time. The activities care plan had no recent updates or changes since 03/8/25 and 06/16/25.
Failure to Provide Bedtime Hygiene and Incontinence Care
Penalty
Summary
The facility failed to ensure that necessary ADL services, specifically bedtime hygiene and incontinence care, were provided for a resident who required assistance with ADLs that could fluctuate based on time of day, mood, pain, or fatigue. The resident’s care plan stated that staff should place the call light within reach, remind the resident to call for assistance, and noted that she did not want to be disturbed during sleep. A facility-reported incident alleged that the resident was left overnight in soiled clothing without bedtime care, and the facility’s investigation found that night shift staff misunderstood the care plan to mean that no evening preparation, bedtime hygiene, or clothing changes were needed because the resident did not use the call light. The resident stated that she had been left in her street clothes overnight and slept in a soiled brief, while morning shift staff reported that she was still dressed in the prior day’s clothing and was heavily saturated with urine when they assumed care. The night-shift CNA stated that the resident had been changed and placed in a nightgown before bed, but the facility determined that statement was false based on the resident’s account, the morning staff statements, and the resident’s condition when found.
Failure to Provide Ongoing Activities for a Resident With Behavioral Needs
Penalty
Summary
The facility failed to ensure Resident #42 was provided an ongoing program of group and individual activities designed to meet the resident’s interests and support physical, mental, and psychosocial well-being. The resident was incapacitated, had no BIMS completed because the resident hardly/never understood, and was documented as being self-directed, wandering throughout the facility, and preferring music and church. The activities policy required resident-centered care and individual activities, but the activities leader reported the facility did not provide individual one-on-one activities for residents and that the resident did not go to group activities often. The resident’s record showed repeated behavioral concerns, including agitation, combativeness, exit-seeking, entering other residents’ rooms, verbal abuse, and resident-to-resident altercations. Clinical Psychological Services recommended consistent redirection, frequent re-orientation, a structured environment, and limited overstimulation. The care plan documented physical aggression episodes toward other residents, but additional behavioral episodes were not updated on the care plan, and social services confirmed there were no resident-to-resident interventions on the plan of care. The Activity Participation Log showed numerous dates when activities were not provided across February through July 2026. Surveyor observation also found the resident wandering in hallways and being redirected by staff. Staff interviews confirmed the resident’s behavioral interventions were inconsistent, the resident liked to walk the halls, and the facility relied on packets of images for self-directed activity rather than providing individual one-on-one activities.
Failure to Address Psychosocial Impact After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a resident who experienced a traumatic event received appropriate treatment and services after a resident-to-resident physical abuse incident that resulted in major injury. Resident #65, who was cognitively intact with a BIMS of 14, was found lying on the floor in the doorway to her room with bleeding from a head wound after Resident #42 was found in her room holding her iPad and a struggle occurred. Resident #65 was transferred to the ED, where trauma imaging showed an acute medial right frontal lobe multifocal subarachnoid hemorrhage with parafalcine and right tentorium subdural hematoma measuring up to 5 mm, with no midline shift. After the incident, Resident #65 reported ongoing fear that Resident #42 would enter her room again, stating staff took the other resident away when she came in and that she was afraid and had to watch her. The record showed Resident #42 had a pattern of entering other residents’ rooms, agitation, combativeness, and interpersonal conflict, with CPS recommending redirection, re-orientation, structured environment, and limited overstimulation. Resident #65’s notes documented denial of needs on one date and denial of psychosocial needs at a later social work visit, and no additional documentation of psychosocial monitoring was found. The resident later had increased anxiety with Buspar ordered and was verbally agitated with staff, while the care plan only addressed the subdural hemorrhage and monitoring for mental status changes and abnormal findings.
Inappropriate Food Texture Served to Resident on Puree Diet
Penalty
Summary
Food was not provided in a form designed to meet an individual resident’s needs when Resident #111, who had an order for a regular diet with dysphagia puree texture and thin liquids, was served a regular consistency roll at lunch. The resident’s diet order also included fortified cereal at breakfast, fortified soup at lunch and dinner, and a two-handled cup with lid for meals. During a dining room observation, Nurse Aide #64 served the resident’s lunch tray and buttered a regular roll for the resident. Before the resident ate it, the State surveyor intervened and had the nurse aide remove the roll. Nurse Aide #64 confirmed the resident was on a puree diet and should not have received a regular roll, stating, “Yeah, you’re right,” and that she did not think it looked right.
Failure to Provide Written Notice and Opportunity Prior to Resident Room Changes
Penalty
Summary
The facility failed to provide written notice to residents prior to making room changes, including the reasons for the change, and did not offer residents the opportunity to visit their new rooms before relocation. Two residents were affected by this deficiency. One resident, who had been living in her room for over two years, was informed verbally by the administrator that she would need to pay an additional monthly charge to remain in her private room. Unable to afford the charge, the resident and her family attempted to resolve the issue with facility administration and the regional director, but received no written communication or invoices regarding the new charges or the policy change. The resident was subsequently told by a social worker that she would be moved to a semi-private room immediately due to non-payment, without prior written notice or opportunity to visit the new room. Another resident was similarly informed verbally that she would need to pay an extra fee to remain in her private room or be moved to a semi-private room. While the resident was at lunch, staff moved her belongings to a new room without her knowledge or consent. The new room did not accommodate her wheelchair, causing her difficulty until she was later moved to a more suitable room. The resident and her daughter both reported that they did not receive any written notification, invoices, or explanations regarding the extra charges or the facility's policy for room changes. Interviews with facility staff confirmed that the decision to begin charging for private rooms was made by the administrator and that residents were only verbally notified of the change. No written notifications were provided to the affected residents, and the process for billing and room changes was handled without documented communication. The interim administrator, who was new to the facility, was unaware of these actions and confirmed that no further residents had been moved since the previous administrator's departure.
Expired Food Safety Certificates Among Dietary Staff
Penalty
Summary
The facility failed to maintain appropriate competencies for food service handling among dietary staff, as evidenced by expired State Food Safety Certificates for both the Certified Dietary Manager and a Dietary Aide. The Certified Dietary Manager's certificate expired and was not renewed until after the survey intervention, while the Dietary Aide worked multiple shifts without a valid certificate before resigning. These lapses in maintaining current food safety training had the potential to affect more than a limited number of residents, as confirmed by record review and staff interviews. The Administrator acknowledged the expired certificates after being informed by the Regional Certified Food Manager.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple observations during a survey. In the kitchen, cookies were found in the freezer with an incomplete date, lacking the year. In the A-Wing pantry, open containers of pickles and cotton candy were not dated, and the refrigerator temperature was recorded at 76 degrees Fahrenheit. In the B-Wing pantry, a sandwich was found unsealed and undated, and multiple individual juice cups were not dated; the refrigerator temperature in this area was 44 degrees Fahrenheit. These findings were confirmed by nursing staff and the regional certified food manager, who stated that opened food items are required to be labeled and dated for seven days and that items in the refrigerator must be dated.
Failure to Maintain Water Management Program for Infection Control
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program specifically related to water management. During a review of facility records, it was found that documentation was not maintained to prevent the growth of waterborne pathogens, and there was no adequate description of the building water system. The flow diagram did not identify the building's water systems for which Legionella control measures are needed, and there was no documentation describing the building water systems using text or testing protocols. The Maintenance Director confirmed that the facility did not maintain the required water management program. This deficiency had the potential to affect all residents residing in the facility, with a census of 116 at the time of the survey.
Failure to Update and Clarify Resident Care Plans
Penalty
Summary
The facility failed to update and clarify care plans for two residents following changes in their clinical status. For one resident, an order for Lovenox, an anticoagulant, was discontinued, but the care plan continued to reference anticoagulant use and associated interventions, such as monitoring for bleeding and providing education on anticoagulant risks. The care plan was not revised to reflect the discontinuation of the medication, and the Administrator confirmed that there was no current order for the anticoagulant at the time of review. For another resident, the care plan lacked clarity regarding the level of assistance required for activities of daily living (ADLs). The care plan stated that either all effort was provided by a helper or that two or more helpers assisted, but interviews with MDS nurses revealed that the level of assistance could fluctuate depending on the resident's cooperation. There was no clear guidance for nursing assistants on when to use one or two-person assistance, and the Administrator acknowledged this lack of clarity.
Failure to Provide Individualized Activities for Bedbound Resident
Penalty
Summary
The facility failed to provide activities designed to enhance a resident's sense of well-being and promote physical, cognitive, and emotional health, as required. A resident with multiple diagnoses, including cardiomyopathy, heart failure, hypertension, muscle weakness, localized edema, bilateral knee pain, diabetes mellitus (on insulin), and lack of coordination, reported being unable to get out of bed and stated that there was little being offered in terms of activities. The resident's care plan listed several interests such as bingo, hunting, fishing, watching TV, baking, cooking, spending time outside, and gardening. However, observations over several days consistently found the resident in bed, primarily watching TV, and not participating in any other activities. Interviews and record reviews revealed that the resident was supposed to have 1:1 activities, but had not received any since a specific date. Activity participation sheets confirmed a lack of documented activities for the resident over a one-week period. Activity staff indicated that the resident was care-planned for self-directed activity and preferred not to leave his room. Despite this, there was no evidence of individualized activities being provided to meet the resident's needs or interests during the survey period.
Failure to Ensure Accurate Medication Orders and Timely Therapy Evaluation
Penalty
Summary
The facility failed to ensure accurate medication orders and timely therapy evaluations for two residents. In one instance, a nurse administered Metoprolol 37.5 mg by splitting a 75 mg tablet, despite the physician's order specifying Metoprolol Tartrate 50 mg tablets to be given at a 37.5 mg dose. The nurse and Director of Nursing later confirmed that the physician's order was inaccurate and did not match the medication supplied by the pharmacy, but the order was not corrected until after surveyor intervention. This discrepancy was not identified or communicated to the physician prior to the surveyor's discovery. In another case, a resident with increased coughing was observed eating and coughing during a meal. Orders were placed for a chest x-ray, laboratory tests, and a Speech Therapy (ST) evaluation. While the chest x-ray and labs were completed, the ST evaluation was not performed as ordered. The administrator confirmed that the speech therapy evaluation did not occur until prompted by the surveyor, indicating a delay in following physician orders for therapy assessment.
Resident Smoking in Non-Designated Area Without Safety Measures
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible, as evidenced by a resident repeatedly smoking in a non-designated area outside the front door on the sidewalk. Despite the presence of a 'No Smoking' sign and the absence of safety equipment such as an ash can, fire blanket, or fire extinguisher in the vicinity, the resident continued to smoke in this area. Interviews with facility leadership revealed inconsistent knowledge and enforcement of the facility's smoking policy, with the Assistant Administrator initially stating there were no smokers and later acknowledging the resident's actions. The Director of Nursing and Corporate Administrator confirmed that the resident was not supposed to smoke in the non-smoking area, and that although a designated smoking area had been created across the parking lot, the resident refused to use it.
Failure to Provide Prescribed Oxygen Flow Rate for Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and multiple complex medical conditions, including traumatic brain injury, paraplegia, and dependence on supplementary oxygen, did not receive the prescribed dose of oxygen as ordered by the physician. The physician's order specified that the resident should receive cool air mist via trach collar continuously with oxygen bled in at 5 liters per minute (LPM). However, during multiple observations on different days, the oxygen concentrator was found to be set below the prescribed rate, at 4.0 LPM and 4.5 LPM, rather than the required 5.0 LPM. These findings were confirmed through direct observation, record review, and staff interview. The discrepancy between the physician's order and the actual oxygen delivery was verified by a registered nurse, who acknowledged that the concentrator was not set to the correct rate as ordered. The resident was observed asleep during one of the checks, and the incorrect oxygen flow persisted across several days before being identified and corrected.
Incomplete POST Form Due to Missing MPOA Signature
Penalty
Summary
The facility failed to ensure that the Physician Orders for Scope of Treatment (POST) form for one resident was completed according to the requirements specified by the West Virginia Center for End-of-Life Care and the West Virginia Health Care Decisions Act. Specifically, a review of the resident's medical record revealed that Section D of the POST form, which mandates the signature of the resident, guardian, or Medical Power of Attorney (MPOA), was not properly completed. Instead of an MPOA signature, only a verbal signature was documented and dated. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the POST form was not correctly completed in a timely manner.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident, as required. On 06/06/24, an anonymous report was made to the corporate hotline alleging that a Nurse Aide (NA) defecated on a male resident and drew pictures on the resident with feces. The Assistant Administrator confirmed participation in some resident interviews following the allegation but expressed uncertainty about the occurrence of the incident, attributing the report to a possibly disgruntled employee. The investigation documentation showed that the issue was reported to the Nurse Aide Registry and that the NA no longer worked at the facility, but it was noted that a situation did occur, though not as described by the caller. However, the investigation lacked witness statements from employees who may have had knowledge of the allegation, and the Administrator confirmed there was no documentation or statements from all staff working at the time or who might have relevant information.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Morgantown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sundale Nursing Home | 0.1 mi | ★★★★★ | 5 | 0 |
| Morgantown Heights Of Journey | 0.7 mi | ★★★★★ | 8 | 0 |
| Madison, The | 1.7 mi | ★★★★★ | 7 | 1 |
| Majestic Care Of Manchin | 15.9 mi | ★★★★★ | 0 | 0 |
| Fairmont Medical Center | 16.8 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 October 2026) and official state health department websites.