Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morgantown Healthcare Center during CMS and state inspections, most recent first.
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The facility did not update a resident's care plan after discontinuing an anticoagulant, leaving outdated interventions in place, and failed to provide clear guidance in another resident's care plan regarding the required level of assistance for ADLs.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.
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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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 | ★★★★★ | 0 | 0 |
| Morgantown Heights Of Journey | 0.7 mi | ★★★★★ | 16 | 0 |
| Madison, The | 1.7 mi | ★★★★★ | 7 | 1 |
| Majestic Care Of Manchin | 15.9 mi | ★★★★★ | 0 | 0 |
| Fairmont Medical Center | 16.8 mi | ★★★★★ | 3 | 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.