Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Pierpont Center At Fairmont Campus during CMS and state inspections, most recent first.
A resident’s MDS assessment was inaccurately coded and did not reflect the individual’s documented physical limitations and ADL needs. The care plan showed the resident required dependent or substantial/maximal assistance for bed mobility, toileting, dressing, personal hygiene, and bathing, and had diagnoses including wheelchair dependence, difficulty walking, and hemiplegia/hemiparesis after a cerebral infarction. However, the MDS coded no upper or lower extremity range-of-motion limitations and no use of mobility devices, and the DON acknowledged that this coding did not match the resident’s actual physical status.
Staff failed to ensure appropriate supervision for an incapacitated resident during off-site urology appointments. Records showed the resident had been determined incapacitated and was dependent on staff for ADLs, and a prior visit had resulted in the resident becoming very upset and agitated, after which the urology provider instructed that the resident should not attend appointments alone. Despite this, the resident was transported by the facility van and left in the waiting room without facility staff present, while the van driver waited in the parking lot and family presence was inconsistent. A urology office receptionist confirmed that the resident had been alone in the waiting room on multiple occasions, nonverbal and appearing very sad.
Care plans were not fully developed or implemented for activities, falls, and AD wishes for 3 residents. One resident’s AD wishes were not included in the care plan, one resident’s planned 1:1 activity visits were not completed and no group activities were attended, and another resident with multiple falls was observed in bed without the ordered bilateral fall mats in place; the DON confirmed the mats were absent and the ADON stated spare mats were available.
Food was served at an unappetizing temperature during a meal pass when only 2 staff members were delivering trays on one hall. The dietary manager measured French fries at 110 degrees Fahrenheit and a hamburger patty at 113 degrees Fahrenheit, below the expected serving temperature. A resident reported cold food, especially at breakfast, and another resident's MPOA said the food is always cold and believed the hall was served last.
Food storage and sanitation deficiencies were observed in the kitchen and tray line. The refrigerator was at 45 degrees, opened boxes of frozen burgers and fish filets were left exposed to air in the freezer, overripe oranges were stored with other produce in the prep cooler, and silverware with dried food spots was observed on the tray line. Facility policy required foods to be wrapped or covered, labeled and dated, and arranged to prevent cross contamination.
Improper Storage of Garbage and Refuse: Surveyors observed that two of three dumpsters were overfilled and their lids could not be completely closed. A dumpster at the front of the facility and one in the rear were both overfull, and the CIA acknowledged the condition during interview. Facility census was 111.
A facility failed to keep complete and accurate medical records for two residents. One resident had a mismatch between an active DNR-selective DNI order and a POST form that listed CPR - FULL Treatments, and another resident had no diet order in the chart until the surveyor intervened; the CCA later confirmed the diet order had not been in the record initially.
Infection control and hand hygiene failures were observed when a laundry aide entered a resident’s room under droplet precautions without PPE or hand hygiene, despite posted isolation instructions. In addition, two residents were served lunch without hand hygiene being completed or offered before the meal, and staff confirmed the omissions.
Failure to submit required five-day follow-up investigation reports: The facility had FRI files for multiple incidents involving residents, but there was no proof the DON or other staff submitted the follow-up investigations to the State Agency within the required timeframe. One incident involved a resident struck in the arm by another resident; the victim had a BIMS of 15 and capacity, and the other resident had capacity and was later diagnosed with a UTI. Staff confirmed there was no evidence the reports were sent.
Two residents were observed in bed with call lights out of reach, including one resident repeatedly stating, "I hurt, I hurt." An LSW confirmed both call lights were not within reach and that each resident felt able to use the call light. Record review showed care plan interventions directing staff to keep the call bell or call light within reach.
Failure to provide bed hold notifications affected two residents reviewed for transfer/discharge. One resident was sent to the hospital and later discharged to another SNF without a bed hold notice, and for another resident the surveyor could not obtain the Bed Hold Notice during review of the hospital transfer. A SW and Nursing Administration confirmed the notices were not sent to the resident or RP, despite facility policy requiring a written Bed Hold Notice & Authorization form when a resident is transferred to a hospital or on therapeutic leave.
A resident with a recent PASARR and newly documented bipolar disorder, depression, and anxiety did not have a new PASARR completed after the change in diagnosis. The DOSS said the facility relies on Meditelecare updates and weekly reports, but there was no evidence that a new PASARR was initiated after the new mental health diagnoses were entered.
A resident’s initial care plan was incomplete, with only a mobility focus documented after recent hospitalization. No care plan focus, goals, or interventions were found for behavior/emotions, dementia care, nutrition, or psychotropic meds, and the CCO confirmed the care plan had only one focus.
A resident’s care plan was not updated after a dialysis catheter was removed and a fistula was placed, leaving outdated procedure-related goals and interventions in place. Another resident’s activity care plan was also not revised despite a marked drop in participation, with the resident observed in bed with no stimulation and the AD confirming no added 1:1 visits or new interventions.
Failure to provide a meaningful activity program for two residents. One resident had a marked drop in activity participation, was observed in bed with no stimulation, and had an activity care plan that had not been updated despite decreased engagement. Another resident with dementia was also observed in bed with no stimulation, and care planned 1:1 visits were not completed as scheduled; the AD said the facility was behind on visits due to staffing.
Failure to Follow Fall Prevention Interventions: A resident with impaired mobility had multiple falls, including a serious injury and falls from bed, and the care plan included bilateral fall mats after a bed fall. During observation, the resident was in bed without the mats in place, and the DON confirmed they were not present while the ADON stated spare mats were available.
Failure to Provide Ordered and Preferred Beverages: Two residents did not receive beverages listed on their tray cards. One resident’s tray card listed apple juice, but the resident reported never receiving it and said preferences were asked for but not honored; an admin staff member confirmed the resident instead asked for punch. Another resident’s tray card listed chocolate milk, but milk was not on the tray, and an admin staff member confirmed it was missing.
The facility failed to ensure their facility-wide assessment identified necessary staffing levels and training requirements. Sections related to staffing, training, and personnel were incomplete, and there was no evidence of a staffing plan or required competencies. The Administrator acknowledged the gaps but could not provide specific sections addressing these issues.
The facility failed to ensure residents had reasonable and ready access to their personal funds, particularly during evenings and weekends. Residents reported difficulties in obtaining money, leading to canceled outings. Staff interviews revealed limited knowledge and resources for handling such requests outside regular office hours.
The facility failed to ensure clean and safe living areas for residents, with heavily soiled P-Tac vents, poor quality furniture, and damaged ceilings. Additionally, a resident's wheelchair was improperly maintained with clear tape holding a cup holder to the armrest.
The facility failed to ensure that residents were free from unnecessary psychotropic medications used for refusal of care. Two residents were prescribed Abilify for refusal of care, and one resident was observed sleeping frequently, with inconsistent documentation of side effect monitoring. The DON acknowledged the inappropriate use of the medication.
The facility failed to update the PASRR for nine residents diagnosed with serious mental disorders upon admission. Diagnoses such as major depressive disorder, bipolar disorder, and psychosis were not accurately reflected in the PASRR documentation, as confirmed by record reviews and staff interviews.
The facility failed to provide information and offer the RSV immunization to residents as recommended by the CDC. Additionally, the facility did not follow a physician's order regarding insulin administration for a resident, with multiple instances of missing blood glucose level documentation in the MARs.
The facility failed to ensure all vials of multi-use insulin were labeled with the initial date they were opened. This deficiency was observed in three vials found in the medication cart, affecting three residents. RN verified that the insulin vials did not have a date indicating when they were first accessed. The DON was informed of these issues.
The facility failed to store food properly, with breaded fish filets exposed in the walk-in freezer, a trash can placed in front of beverage dispensers, a missing floor tile, and debris on the freezer floor. The Dietary Manager confirmed these issues.
The facility failed to maintain a safe, clean, and comfortable environment for its residents, with issues including heavily soiled P-Tac vents, poor quality furniture, leaking ceilings, and a resident's wheelchair improperly repaired with tape. These deficiencies indicate a lack of effective action by the Quality Assessment and Assurance committee.
The facility failed to maintain an infection prevention and control program, with deficiencies in bedpan storage, laundry services, and ice machine use. Used bedpans were improperly stored, the laundry room lacked proper separation and ventilation, and a resident was seen retrieving ice from a community ice machine despite being instructed not to.
A resident with lactose intolerance received a grilled ham and cheese sandwich despite having cheese listed as a dislike on her meal ticket. The resident's care plan indicated she should be provided with Lactaid milk and monitored for nutritional intake due to multiple health conditions. The meal ticket did not include cheese sandwiches under dislikes, leading to the resident receiving inappropriate food. The DON was informed and acknowledged the oversight.
The facility failed to notify a resident's representative in a timely manner when an antibiotic was ordered to treat a dental abscess. The resident's MPOA was unaware of the infection and treatment, despite noticing bruising and swelling during a visit. The DON confirmed the lack of notification.
The facility failed to ensure a resident's privacy and confidentiality by posting signs with personal care information in her room without family request or care planning. The resident lacked decision-making capacity, and the signs were visible to others.
The facility failed to report a resident fall resulting in serious injuries, including a nasal bone fracture, to the appropriate state agencies within the required two-hour timeframe. The incident was reported four days later due to the absence of both social workers over the Thanksgiving holiday.
The facility failed to notify the State Ombudsman of a resident's transfer to another LTC facility. This was confirmed during a medical record review and an interview with the Licensed Social Worker.
The facility failed to update the PASARR for a resident diagnosed with schizophrenia after admission. The PASARR only indicated a seizure disorder, and the Director of Nursing acknowledged the missing diagnosis.
The facility failed to develop a comprehensive person-centered care plan for discharge planning for a resident. A medical record review revealed that the resident was discharged without a developed care plan, which was confirmed by the LSW.
The facility failed to update a resident's care plan after the removal of an indwelling urinary catheter. This was confirmed during a medical record review and an interview with the DON, highlighting a lapse in maintaining accurate and current care plans.
A resident reported only receiving bed baths despite a preference for showers and a desire to have their hair washed. The DON confirmed the resident was scheduled for baths, but records showed showers were documented. LPN acknowledged documentation issues, and the DON confirmed the discrepancy, constituting a deficiency in care.
A facility failed to ensure a safe environment when a prescribed medication, Amiodarone, was found on the floor in a resident's room. The DON confirmed that nurses must ensure medications are swallowed before documenting administration, indicating a lapse in supervision and medication administration.
The facility failed to ensure residents were free from unnecessary psychotropic medications. One resident had an order for Abilify for refusal of care, which the DON acknowledged was inappropriate. Another resident received Abilify daily without proper side effects monitoring, and the MAR inconsistently documented the resident's condition.
The facility failed to provide appropriate assistive devices to a resident who needed them to eat independently. Despite the care plan indicating the use of a proval cup due to paralysis affecting the left extremities, the resident was not provided with the required cup because they did not like it, as stated by a nurse aide.
The facility failed to maintain accurate medical records for two residents. One resident's preference for showers was not honored, and documentation inaccurately recorded showers instead of bed baths. Another resident's side effects from psychotropic medication were not accurately documented, despite observations suggesting potential side effects. The DON acknowledged these discrepancies.
Inaccurate MDS Coding of Resident Functional Status and Mobility Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an accurate MDS assessment reflecting a resident’s physical status. Record review for Resident #38 showed an ADL care plan indicating the resident required dependent assistance of two staff for bed mobility; setup and substantial/maximal assist of one for toileting; substantial/maximal assist of one for dressing; partial/moderate to dependent assist of one for personal hygiene; and substantial/maximal assist of one for bathing. The resident’s diagnoses included dependence on a wheelchair, difficulty in walking, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side. Despite these documented functional limitations and care needs, the MDS with an ARD of 11/11/25 was coded in Section GG0115 as having 0 upper and lower extremity limitations in range of motion, and Section GG0120 as using no mobility devices. In an interview, the DON confirmed that the MDS coding was incorrect based on the resident’s physical status. This failed practice was identified as a random opportunity for discovery and was determined to have the potential to affect a limited number of residents during the complaint survey, with a facility census of 108 and the deficiency specifically involving Resident #38.
Failure to Supervise Incapacitated Resident During Off-Site Urology Appointments
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not ensuring supervision for an incapacitated resident during out-of-facility urology appointments. Record review showed that the resident had a Physician's Determination of Capacity form indicating incapacity and a care plan documenting dependence on staff for ADLs including bathing, grooming, dressing, eating, mobility, transfers, locomotion, and toileting due to limited mobility. A general patient note documented that during a prior urology visit, the resident became very upset, agitated, and destructive when required to wait, and the urology provider reported that the resident was not to come to appointments alone. Despite this, documentation showed that the resident had multiple subsequent urology appointments to which he was transported by the facility van. Interviews further confirmed that the resident was left unsupervised at these appointments. The resident’s health care surrogate stated that facility staff leave the resident at appointments without anyone from the facility supervising him, particularly at the urology office, and that he is left sitting in the waiting room. The activity assistant/van driver reported that for residents without capacity, an aide typically accompanies them if family cannot come, but in this case, the driver took the resident inside the urology office and then waited in the van in the parking lot, noting that the resident’s son was supposed to come but was only present once or twice. A receptionist at the urology office stated that, during the time she had worked there, the resident was definitely alone in the waiting room on at least two occasions, that he did not talk, and that he sat there looking very sad.
Care plans not developed or implemented for activities, falls, and Advance Directives
Penalty
Summary
The facility failed to develop and/or implement care plans related to activities, fall interventions, and Advance Directives for 3 of 31 residents reviewed. For one resident, the care plan for Advance Directive wishes was reviewed and found not to include the resident’s Advanced Directives, and the care plan was confirmed by the Corporate Compliance Advisor. For another resident, observations on two separate days showed the resident lying in bed with the door shut due to COVID precautions and no stimulation in the room. The resident’s activity care plan stated the resident would receive 2 to 3 one-on-one visits weekly, but review of activity participation sheets for multiple months showed those visits were not completed as planned and the resident had not attended any group activities. During interview, the AD stated the facility was behind on one-on-one visits because staff were being added. For the third resident, record review showed 6 falls since 10/01/25, including one fall with serious injury and two falls from bed, one causing a skin tear above the right eye. The falls care plan included bilateral fall mats as an intervention after a fall from bed, but an observation showed the resident in bed without the bilateral fall mats in place. The DON confirmed the mats were not in place and stated they might be getting cleaned, while the ADON stated the facility did have spare fall mats and that an order is placed when needed and Maintenance brings them up.
Food Served Cold During Meal Pass
Penalty
Summary
Food and drink were not served at an appetizing temperature during meal service. During observation of the 220 hall meal pass, only 2 staff members were delivering all trays to residents on that hall, and the District dietary manager took food temperatures at the time of service and found French fries at 110 degrees Fahrenheit and a hamburger patty at 113 degrees Fahrenheit, confirming the food was not served at 120 degrees Fahrenheit. Resident #24 reported during an initial interview that the food was cold, especially at breakfast. Resident #112's MPOA stated that the resident's food is always cold and believed it was because the hall is the last to be served.
Food Storage and Tray Line Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial brief tour of the kitchen, the Kitchen Dietary Manager acknowledged that the kitchen refrigerator temperature was 45 degrees, that an opened box of frozen burgers and an opened box of frozen fish filets in the freezer were left exposed to air with the plastic wrap not sealed, and that overripe oranges with brown spots were stored in the same container with other produce in the prep cooler. A review of facility policy on cold food storage stated that all foods are to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination. During meal prep tray line observation, the Corporate Dietary Manager also acknowledged silverware with dried food spots on the tray.
Improper Storage of Garbage and Refuse
Penalty
Summary
The facility failed to store garbage and refuse in a proper manner when surveyors observed that two of three dumpsters were overfilled and their lids could not be completely closed. During an initial observation with the Corporate Interim Administrator, a dumpster on the front side of the facility was seen overfilled with the lid unable to close, and in the rear of the facility, the left of two dumpsters was also observed to be overfull with the lid unable to close. During an interview shortly after the observation, the Corporate Interim Administrator acknowledged that the dumpsters were overfilled and that the lids were unable to be completely closed. The facility census was 111.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents involving a Physician's Order of Treatment (POST) form and a diet order. For Resident #24, the record showed an active order for DNR-selective DNI, but the resident's POST form dated [DATE] stated CPR - FULL Treatments, and the difference between the order and care plan was confirmed by the Corporate Compliance Advisor. For Resident #126, a diet order was not found in the medical record during review, and the order was not present until the state surveyor intervened; later that day, the Corporate Compliance Advisor confirmed there was no initial diet order in the record and stated, "The Order is in there now."
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an infection control program designed to help prevent the spread of disease. During observation on 01/06/2026 at 12:40 PM, a Droplet Precautions sign was posted on Resident #52’s door with instructions to perform hand hygiene before and after patient contact, wear an N95 respirator, gown, face shield, and gloves, keep the room door closed, and use other specified precautions. Despite these instructions, Laundry Aide #52 entered the resident’s room, walked beside the bed, and placed socks in the drawer without putting on PPE or performing hand hygiene. When asked about the sign, the aide stated she had been told they did not have to wear that equipment to just put up the laundry. The facility also failed to ensure resident hand hygiene before meals. The facility policy for Patient Hand Hygiene stated that staff should assist residents with hand hygiene after toileting and before meals, as needed. On 01/05/2026 at 12:25 PM, Resident #86 received a meal tray without hand hygiene being completed, and Nursing Assistant #38 confirmed no hand hygiene had been performed prior to lunch. On 01/05/2026 at 12:36 PM, Resident #97 was also not offered hand hygiene before lunch, and Social Worker #36 confirmed the resident did not receive hand hygiene and stated they usually have packets and just hand out trays.
Failure to Submit Required Five-Day Follow-Up Investigation Reports
Penalty
Summary
The facility failed to thoroughly investigate reportable incidents and failed to report the results of those investigations to the State Agency within five working days of the incidents, including the required corrective action when an allegation was verified. A facility reported incident dated 04/13/25 involving Resident #70 and another dated 06/06/25 involving Resident #71 were reviewed. The facility had Five Day Follow-up Investigation Reports in its file for both incidents, but there was no proof that either report had been submitted to the State Agency. The DON confirmed there were no documentation emails available, stated the Social Worker who reported the incidents no longer worked at the facility, and reported that corporate was trying to retrieve the emails from her computer. The DON also stated the emails were deleted after 90 days and corporate could not retrieve them, and confirmed the Five Day Follow-up reports were not submitted to the State Agency. The facility also failed to show that a five day follow-up investigation report was submitted for a documented change in condition involving Resident #121 and Resident #73. The record showed that on 04/19/25 the victim was struck in the arm by Resident #73. Resident #121 had a BIMS score of 15 and had capacity, and there were no other incidents in the medical record alleging abuse. Resident #73 was diagnosed shortly after the incident with a UTI and had capacity at the time of the alleged incident. During survey, the facility reported incident documents for both residents were reviewed, but there was no documentation readily available to show that the five day follow-up investigation report had been sent to the State Agency. Employee #56 verified that there was no evidence the report was submitted.
Call Lights Not Kept Within Reach of Residents
Penalty
Summary
The facility failed to keep needed items in reach of residents and did not provide necessary assistance to maintain resident independence by not keeping call lights within reach. During observation, Resident #51 was lying in bed repeatedly saying, "I hurt, I hurt," and the resident's call light was found lying behind the bed. A Licensed Social Worker confirmed that the call light was not in reach and that the resident felt like she could use it. Record review showed a fall care plan intervention directing staff to encourage the resident to use the call bell for staff assistance. Resident #72 was observed in bed with the bed in the upright position, and the resident's call light was draped over the head of the bed and not within reach. The Licensed Social Worker also confirmed that this resident's call light was not in reach and that the resident felt like she could use it. Record review showed a nutritional care plan intervention stating to place the call light within reach at all times.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notification for residents who were discharged or transferred, affecting two of two residents reviewed for discharge/transfer, Resident #115 and Resident #117. For Resident #115, the medical chart showed a hospitalization, and the facility did not provide a bed hold notification when the resident was discharged to the hospital; Social Worker #56 confirmed there was no bed hold notification and stated the resident was going to discharge anyway to another facility, then went to the hospital and was discharged from the hospital to another skilled nursing facility. For Resident #117, the surveyor requested the Bed Hold Notice, Transfer Notice, and Ombudsman Notification during review of the resident’s transfer to the hospital, but the Bed Hold Notice was not provided; Nursing Administration #82 later stated she notified the Ombudsman but did not send a Bed Hold Notice to the resident or responsible party. The facility policy titled AR102 Bed-Holds states that when a resident is transferred out of the Center to a hospital or on therapeutic leave, the designee will provide the resident/representative with the written Bed Hold Notice & Authorization form.
Failure to Update PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for one resident after new diagnoses of bipolar disorder, depression, and anxiety were added to the record. The resident’s most recent PASARR had been completed on 07/28/25, and the new mental health diagnoses were documented on 08/06/25. During interview, the Director of Social Services stated that the facility uses Meditelecare for psych services and is informed to update the PASARR when a diagnosis is updated, with weekly reports sent showing who was seen and any changes. Review of the facility policy stated that Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results when it is learned after admission that PASARR was not completed or is incorrect, or when there is a significant change in status resulting in new evidence of possible mental disorder, intellectual disability, or a related condition. There was no evidence that the Director of Social Services initiated a new PASARR after the new diagnoses were given.
Incomplete Baseline Care Plan
Penalty
Summary
The facility failed to ensure that Resident #126 had a baseline care plan developed and implemented with the instructions needed to provide effective and person-centered quality care within 48 hours of admission. On 01/05/26, the resident’s care plan was initially reviewed because no diet order was found in the medical record. The Care Plan Report showed only one focus related to assistance with mobility after a recent hospitalization. Further review found no care plan focus, goals, or interventions for behavior/emotions, dementia care, nutrition, or psychotropic medications on the resident’s initial care plan. The care plan was updated on 01/05/26 following surveyor intervention, and at 1:55 PM the Corporate Compliance Officer confirmed that the care plan had only one focus for mobility.
Care plans not revised for dialysis access change and decreased activity participation
Penalty
Summary
The facility failed to ensure that Resident #15’s care plan was revised after a dialysis catheter was removed from the resident’s chest and a fistula was placed in the arm. The care plan still reflected that the resident was scheduled for outpatient surgery on 10/21/25 to have the dialysis catheter removed, with goals and interventions written for the time of the procedure. During interview, the resident stated the catheter had been removed a few months earlier, around October, and that the site had healed with no issues. Corporate Nurse #129 acknowledged that the resident’s care plan needed to be revised. The facility also failed to revise Resident #51’s activity care plan despite a documented decrease in activity participation. Observation showed the resident lying in bed and repeatedly saying, “I hurt, I hurt,” with no stimulation in the room, and later again lying in bed with no stimulation. Record review showed that in 11/2025 the resident participated in five individual activities daily and at least one group activity weekly, but in 12/2025 and 01/2026 to date participation dropped to two individual activities daily with refusals, sleep, or no documentation for group activities. The activity care plan, last revised on 02/12/25, still described the resident’s preferences and routines and had no additional interventions added despite the decline. The Activity Director confirmed the resident’s participation had decreased since 11/2025 and that she had not been added to one-to-one visits.
Failure to Provide Meaningful Activity Program
Penalty
Summary
The facility failed to provide a program of activities to meet the interests and support the physical, mental, and psychosocial well-being of two residents reviewed for activities. Resident #51 was observed lying in bed on two occasions, repeatedly saying, “I hurt, I hurt,” with no stimulation in the room and later lying in bed turned toward the separation curtain with no stimulation in the room. Record review showed a significant decrease in activity participation: in 11/2025 the resident was documented for five individual activities daily and at least one group activity weekly, along with accepting Daily Chronical Delivery, but in 12/2025 and 01/2026 to date the resident was documented for only two individual activities daily and had refused, been asleep, or had no documentation for group participation. The activity care plan, last revised 02/12/25, identified that the resident enjoyed walking the halls using a rollator, socializing, and eating in the dining room, and included interventions to encourage preferences such as watching TV, relaxing, walking the halls, and religious services. Resident #52 was observed in bed with the door shut due to COVID precautions, and no stimulation was on in the room during both observations. The activity care plan stated the resident had cognitive loss/dementia, did not wish to engage in group activities, enjoyed some individual activities such as social and pet visits, and spent most of the time resting in the room. The plan called for 2 to 3 one-on-one visits weekly, but review of activity participation sheets for 11/2025, 12/2025, and 01/2026 to date showed the one-to-one visits were not completed as care planned and the resident had not attended any group activities. The Activity Director stated the facility was behind on one-to-one visits because of staffing.
Failure to Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure the environment under its control was as free from accident hazards as possible by not ensuring fall prevention interventions were followed for Resident #5. Record review showed the resident had six falls from 10/01/25 to present, including one fall with serious injury and two falls from bed, one of which caused a skin tear above the right eye. The falls care plan identified the resident as at risk for falls due to impaired mobility and listed bilateral fall mats as an intervention initiated on 12/11/25 after a fall from bed. However, during observation on 01/08/26 at 8:40 AM, Resident #5 was lying in bed without bilateral fall mats in place. The DON confirmed the mats were not in place and stated they might be getting cleaned, and the ADON stated the facility did have spare fall mats available when others were being cleaned.
Failure to Provide Ordered and Preferred Beverages
Penalty
Summary
The facility failed to ensure staff supported residents’ nutritional well-being while respecting individual dietary choices and preferences. The facility’s policy stated that food allergies, intolerances, dislikes, and food and fluid preferences were to be entered into the resident profile in the menu management software system. During record review, staff interview, and resident interview, Resident #24’s tray card listed apple juice 8 oz, but the resident did not receive apple juice and stated, “I’ve never gotten apple juice. When I first came in they asked my preference, but did not get it.” Administration Staff #120 confirmed the resident did not get apple juice and reported the resident asked for punch. Resident #97’s tray card listed chocolate milk, 1 cup, but the resident did not receive milk, and Administration Staff #120 confirmed the resident did not have milk on the tray.
Incomplete Facility-Wide Assessment on Staffing and Training
Penalty
Summary
The facility failed to ensure their facility-wide assessment identified the necessary staffing levels and training requirements to provide adequate care and services for residents. During a review of the Facility Assessment, it was found that sections related to staffing, training, and personnel were incomplete. Specifically, the sections meant to document the total number, average, and range of staff required to meet resident needs were left blank. Additionally, there was no evidence that the facility identified the types of staff members, healthcare professionals, and medical practitioners needed to support and care for residents. The facility also did not describe their staffing plan or the training and competencies required for staff to meet the needs of the resident population. In an interview, the Administrator acknowledged that the facility's assessment was intended to include both the resident population and the resources needed to care for them. However, when asked to identify where the assessment addressed staffing levels, skills, competencies, and training programs, the Administrator was unable to provide specific sections that contained this information. The Administrator later indicated that these questions were addressed in the Acuity and Cognitive Sufficiency Analysis Summary sections, but a review of these sections showed they were also incomplete.
Failure to Provide Residents with Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had reasonable and ready access to their personal funds held by the facility. During a resident council meeting, four residents expressed concerns about difficulties in obtaining money during evenings and weekends. One resident mentioned uncertainty about accessing funds after office hours, while another noted that outings had to be canceled due to the unavailability of funds. Interviews with staff, including a receptionist and several nurses, revealed that the facility kept an emergency fund of $50 for such situations, but this amount was limited and had to be rationed among residents. Staff members were generally unaware of how to handle requests for funds outside of regular office hours, leading to delays in residents accessing their money. The receptionist confirmed that there had been instances where outings were canceled due to insufficient funds, although the exact reasons were unclear. Licensed Practical Nurses (LPNs) and a Registered Nurse (RN) interviewed admitted they did not know how residents could access their funds during evenings or weekends and would typically advise residents to wait until the next business day. The RN mentioned that they were not allowed to handle resident funds and would need to consult a nurse on call for guidance, but ultimately, residents would have to wait until office staff were available. This lack of access to personal funds affected the residents' ability to participate in activities and manage their financial affairs as needed.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure the living areas for residents were clean, safe, and sanitary. During a tour, it was discovered that the P-Tac vents in several rooms were heavily soiled with a thick layer of debris, and the maintenance helper confirmed that these should be cleaned or replaced monthly. However, documentation of the last cleaning was not provided, and the records indicated the last cleaning was done two months prior. Additionally, the facility had poor quality furniture, with nightstands in several rooms peeling and exposing particle boards, making them difficult to clean properly. Despite the administrator's acknowledgment of the issue, the same nightstands were found in use in resident rooms during a follow-up observation. The facility also had issues with damaged ceilings, with one resident reporting a leaking ceiling for over two months, resulting in dark brown stains and a strong odor of mildew. The maintenance staff confirmed the leak but provided inconsistent information about when it started. Another room had a severely damaged ceiling with plaster falling off and a strong mildew odor, and the resident had to be moved to another room. Additionally, a resident's wheelchair was found with a large amount of clear tape holding a cup holder to the armrest, which was not properly addressed until two days later. These deficiencies indicate a failure to maintain a safe, clean, and comfortable environment for the residents.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications used for refusal of care. This deficiency was identified for two residents. Resident #5 had an order for Abilify, an antipsychotic medication, prescribed for refusal of care, combative behavior, and aggression. The Director of Nursing (DON) acknowledged that medications should not be given for refusal of care. Similarly, Resident #91 had an order for Abilify to be administered at bedtime for mood and refusal of care. The resident was observed sleeping at various times throughout the day, and the Medication Administration Record (MAR) indicated that the resident received Abilify daily in February and March. The MAR also showed inconsistent documentation regarding monitoring for side effects, with some days marked as 'Not Applicable' despite the medication being administered. The DON was informed about the inappropriate use of Abilify for refusal of care and the discrepancies in monitoring for side effects. The observations and records indicated that the facility did not adhere to proper protocols for administering psychotropic medications, leading to unnecessary medication use for the residents involved.
Failure to Update PASRR for Residents with Mental Disorders
Penalty
Summary
The facility failed to update the Pre Admission Screening and Resident Review (PASRR) for residents diagnosed with serious mental disorders upon admission. This deficiency was identified for nine out of ten residents reviewed during the long-term care survey process. Specifically, residents with diagnoses such as major depressive disorder, bipolar disorder, and psychosis were not accurately reflected in their PASRR documentation. For instance, Resident #82, #38, and #6 were admitted with major depressive disorder, but their PASRRs did not mark this diagnosis. Similarly, Resident #32 and #29 had bipolar disorder, but their PASRRs failed to identify this condition. Additionally, Resident #37 and #102 had diagnoses of psychosis and bipolar disorder, respectively, which were not updated in their PASRRs. Resident #77 also had an admitting diagnosis of bipolar disorder that was not reflected in the PASRR documentation. The deficiencies were confirmed through record reviews and staff interviews. The Director of Nursing (DON) and Social Workers acknowledged the missing diagnoses in the PASRRs and confirmed that new PASRRs had not been completed to reflect the residents' current mental health conditions. The failure to update the PASRRs meant that the need for specialized services was not assessed, potentially impacting the care provided to these residents. The facility census at the time of the survey was 106 residents.
Failure to Provide RSV Immunization and Follow Insulin Orders
Penalty
Summary
The facility failed to provide information and offer the Respiratory Syncytial Virus (RSV) immunization to residents as recommended by the CDC. A review of facility documents revealed that none of the 106 residents had been provided educational information about the risks and benefits of receiving the RSV vaccination. The Infection Preventionist confirmed that the facility did not offer the RSV vaccine, despite CDC recommendations for adults aged 60 and older to receive the vaccine to protect against severe RSV. The CDC had made the RSV vaccine available in early August 2023, and simultaneous administration with other vaccines was considered best practice. Additionally, the facility failed to follow a physician's order regarding insulin administration for a resident. The resident had an order for insulin on a sliding scale, but a review of the Medication Administration Records (MARs) for October, November, and December 2023 revealed multiple instances where nursing staff failed to obtain blood glucose levels and left the MARs blank. The Director of Nursing acknowledged that the documentation on these dates did not meet professional standards of practice, as nursing staff should have taken the resident's blood glucose level, documented it, and assessed if Novolog needed to be administered.
Failure to Label Multi-Use Insulin Vials
Penalty
Summary
The facility failed to ensure all vials of multi-use insulin were labeled with the initial date they were opened. This deficiency was observed in three out of three vials found in the medication cart, affecting residents #32, #71, and #72. On 03/13/24 at 9:06 AM, RN #28 verified that the insulin vials for these residents did not have a date indicating when they were first accessed. Specifically, a multi-use vial of Lispro for Resident #32, a multi-use vial of Lantus for Resident #71, and a multi-use vial of Levemir for Resident #72 were found without the required date. According to the CDC, a multi-use vial should not be used longer than 30 days once punctured. The Director of Nursing (DON) was informed of these issues on 03/13/24 at 11:30 AM.
Improper Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During a kitchen tour, it was observed that a box of breaded fish filets was not sealed properly, exposing the filets to the elements in the walk-in freezer. Additionally, a trash can was situated in front of the beverage dispensers, causing staff to lean over the trash can to fill beverage pitchers. A large section of a floor tile was missing beside the ice machine, and the floor of the walk-in freezer had debris and food particles under the shelving unit. The Dietary Manager verified these issues during an observation and interview.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The P-Tac vents in rooms 301, 302, 303, 304, and 305 were found to be heavily soiled with a thick layer of debris, and the maintenance helper confirmed that these should be cleaned or replaced monthly. However, documentation showed the last cleaning was done two months prior. Additionally, the facility had poor quality furniture, with nightstands in several rooms peeling and exposing particle boards, making them difficult to clean properly. Despite the administrator's acknowledgment of the issue, the same damaged furniture was found in use in multiple rooms during the survey. The facility also had issues with damaged ceilings. In one room, a resident reported a leaking ceiling that had been an ongoing problem for two months, with dark brown stains and a strong odor of mildew. Another room had a leaking ceiling with plaster falling off, exposing discolored and damaged sheetrock. The maintenance staff and district maintenance manager were aware of the issue, but there was no evidence of timely action taken to address the leaks. The affected residents had to be moved to other rooms due to the unsafe conditions. Furthermore, a resident's wheelchair was found with a large amount of clear tape holding a cup holder to the armrest. Despite a licensed practical nurse's promise to put in a work order to fix it, the tape was still present the following day. It was only on the third day that the cup holder was properly attached. These deficiencies indicate a failure by the facility's Quality Assessment and Assurance committee to make good faith attempts to correct known quality deficiencies, compromising the safety and comfort of the residents.
Infection Control Deficiencies in Bedpan Storage, Laundry Services, and Ice Machine Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies. Observations revealed that used bedpans for three residents were stored together without covers in a bathtub, which was confirmed by a nurse aide who stated they should be stored in bags with names on them. Additionally, the laundry services were found to be inadequate, with no sealed separation between the soiled and clean laundry areas, and no negative air flow to prevent contamination. The laundry room had bags of soiled laundry on the floor, lint buildup on washer filters, and non-functional vents with dust and dirt accumulation. The Laundry Supervisor confirmed these issues and acknowledged that the facility was aware of them but had not yet corrected them. Another deficiency was observed when a resident was seen retrieving ice from a community ice machine, despite being told multiple times not to do so. The Director of Nursing was informed of this incident and expressed uncertainty about how to prevent it from happening again. These practices had the potential to affect all residents in the facility, compromising the overall infection control and prevention measures.
Failure to Honor Resident's Dietary Choices
Penalty
Summary
The facility failed to honor a resident's dietary choices, specifically regarding lactose intolerance. On 03/11/24, the resident reported receiving a grilled ham and cheese sandwich despite being lactose intolerant and having cheese listed as a dislike on her meal ticket. The resident's care plan indicated she should be provided with Lactaid milk and monitored for nutritional intake due to multiple health conditions, including Type 2 Diabetes Mellitus, adult failure to thrive, hypothyroidism, major depressive disorder, Chronic Kidney Disease Stage 3B, and Congestive Heart Failure. The meal ticket did not include cheese sandwiches under dislikes, leading to the resident receiving inappropriate food. The Director of Nursing was informed and acknowledged the oversight.
Failure to Notify Resident's Representative of Change in Care
Penalty
Summary
The facility failed to notify the resident's representative in a timely manner when there was a change in care. Specifically, an antibiotic, Amoxicillin, was ordered for a resident on 03/08/24 to treat a dental abscess, but the resident's Medical Power of Attorney (MPOA) was not informed of this new medication order. The resident had swelling and bruising on the left jaw area, which was noted in the medical records, but there was no evidence that the MPOA was notified about the dental abscess or the antibiotic treatment. During a telephone interview, the resident's MPOA expressed concern about the bruising on the resident's cheek and neck, which she noticed during a visit. The MPOA was unaware of the tooth infection and the antibiotic treatment. The Director of Nursing confirmed that there was no evidence that the MPOA had been notified of the new order for Amoxicillin to treat the dental abscess.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure a resident's right to privacy and confidentiality. During a visit, it was observed that a resident had three signs posted in her room containing personal care information, such as 'I do not get up alone,' 'I get help for the bathroom,' and 'No straws.' The resident lacked decision-making capacity and had a family member serving as her Medical Power of Attorney (MPOA), who confirmed that the signs were not requested by the family. The Social Worker confirmed that the signs were visible to others and included clinical and personal information, and that the need for the signage was not care planned.
Failure to Timely Report Resident Fall with Serious Injury
Penalty
Summary
The facility failed to report a resident fall resulting in serious bodily injury to the appropriate state agencies in a timely manner. This deficiency was identified during a review of records and staff interviews. Specifically, a resident fell in her bathroom and was subsequently diagnosed with multiple injuries, including a nasal bone fracture. Despite the facility's knowledge of the serious injury, the incident was not reported within the required two-hour timeframe and was instead reported four days later. The delay in reporting was attributed to the absence of both social workers over the Thanksgiving holiday.
Failure to Notify State Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide the Notice of Transfer to the State Ombudsman for a resident who was transferred to another long-term care facility. This deficiency was identified during a medical record review on 03/13/24, which revealed that the notice was not sent when the resident was transferred on 12/12/23. The Licensed Social Worker confirmed in an interview that the Notice of Transfer was not sent to the State Ombudsman for the resident in question.
Failure to Update PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to update the Pre Admission Screening and Resident Review (PASARR) for a resident diagnosed with a serious mental disorder after admission. Specifically, a record review for a resident revealed that the resident was admitted to the facility and later diagnosed with schizophrenia, but the PASARR was not updated to reflect this diagnosis. The PASARR only indicated a seizure disorder as a current diagnosis. The Director of Nursing was notified and acknowledged the missing diagnosis from the resident's PASARR.
Failure to Develop Discharge Planning Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for discharge planning for Resident #105. During a medical record review on 03/13/24, it was revealed that Resident #105 was discharged on an unspecified date without a developed care plan for discharge planning. This deficiency was confirmed in an interview with the Licensed Social Worker (LSW) on 03/13/24 at 9:20 AM, who verified that the care plan had not been developed for discharge planning for Resident #105. The facility census at the time was 106 residents.
Failure to Revise Care Plan After Urinary Catheter Removal
Penalty
Summary
The facility failed to revise a person-centered comprehensive care plan for a resident following the removal of an indwelling urinary catheter. Specifically, the care plan for Resident #84 was not updated to reflect the removal of the urinary catheter on 02/05/24. This deficiency was identified during a medical record review on 03/13/24 and confirmed through an interview with the Director of Nursing (DON) on the same day. The facility's census at the time was 106 residents, and this issue was noted for one of the four resident care plans reviewed for urinary catheter care during the Long-Term Care Survey Process (LTCSP).
Failure to Provide Preferred Bathing Method and Hair Washing
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #38, who had been at the facility for a couple of weeks, reported only receiving bed baths despite a preference for showers and a desire to have their hair washed. The Director of Nursing (DON) confirmed that the resident was scheduled to receive baths on Wednesdays and Saturdays, but records indicated that showers were documented on several dates. However, the resident confirmed that they had only received bed baths during this period. Licensed Practical Nurse (LPN) #140 acknowledged that there were issues with documentation from the aides, and upon review, it was found that Nurse Aides #11 and #160 had incorrectly documented showers instead of bed baths. The DON was notified and acknowledged the discrepancy, confirming that Resident #38 had not had their hair washed as per their preference. This failure to provide the preferred method of bathing and hair washing constitutes a deficiency in the care provided to the resident.
Medication Found on Floor in Resident's Room
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards, as evidenced by a prescribed medication found on the floor in a resident's room. During an in-room visit, an unidentified white, round, scored pill was discovered on the floor in front of the resident's bed. The pill was later identified by an LPN as Amiodarone, a medication prescribed for atrial fibrillation (AFib). The presence of the medication on the floor indicates that the resident may not have ingested the medication as intended, posing a potential health risk given the serious nature of the medication's use and its boxed warnings from the FDA. The Director of Nursing (DON) confirmed awareness of the incident and stated that it is a professional standard of practice for nurses to ensure all medications have been swallowed before documenting successful administration on the medication administration record (MAR). The failure to adhere to this standard practice led to the medication being found on the floor, highlighting a lapse in the supervision and administration of medication within the facility. The facility census at the time was 106 residents.
Failure to Ensure Residents Were Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications. For Resident #5, an order for Abilify was written to address refusal of care, combative behavior, and aggression. The Director of Nursing (DON) acknowledged that medications should not be given for refusal of care. Additionally, Resident #5 had a PRN order for Xanax that extended beyond the 14-day limit without a provided rationale, which the DON could not justify during the survey. No further information was available at the close of the survey regarding this issue. For Resident #91, an order for Abilify was also written to address refusal of care. The resident was observed sleeping at various times over several days, and the Medication Administration Record (MAR) indicated that Abilify was administered daily in February and March. Despite this, the MAR inconsistently documented the resident's freedom from side effects, with some days marked as 'Not Applicable.' The DON acknowledged the inappropriate order for Abilify, the resident's frequent sleeping, and the inconsistent documentation of side effects monitoring.
Failure to Provide Assistive Devices for Eating
Penalty
Summary
The facility failed to provide appropriate assistive devices to a resident who needed them to maintain or improve their ability to eat independently. During a noon meal observation, Resident #37 was found having issues drinking her milk. The resident's tray card indicated the use of a spout cup, but Nurse Aide #67 stated that the resident did not like the spout cup and therefore it was not provided. A review of the resident's care plan revealed that the resident was dependent on assistance for activities of daily living (ADLs) due to paralysis affecting the left extremities and required the use of a proval cup (blue handles) for all liquids. The Corporate Nurse confirmed that the resident needed the blue-handled cup as per the care plan and diet order for dysphagia advanced texture.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For Resident #38, the facility did not accurately document the type of ADL care provided. Despite the resident's preference for showers and the facility's schedule indicating showers on specific days, the resident only received bed baths. Documentation inaccurately recorded that the resident received showers on multiple dates, which was confirmed to be incorrect by both the resident and an LPN. The LPN admitted to not being aware of the documentation requirements and acknowledged ongoing issues with aide documentation accuracy. For Resident #91, the facility failed to accurately record side effects of psychotropic medications. The resident was prescribed Abilify for mood target behavior and was observed sleeping at various times, suggesting potential side effects. However, the MAR consistently indicated that the resident was free from side effects, except for two days marked as not applicable. The DON acknowledged the discrepancies in documentation and the need for accurate monitoring of side effects.
What surveyors are citing around you — mapped
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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 112 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 Fairmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tygart Center At Fairmont Campus | 0 mi | ★★★★★ | 18 | 0 |
| Fairmont Medical Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Fairmont Rehabilitation And Healthcare Center Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Manchin | 2.5 mi | ★★★★★ | 0 | 0 |
| St. Barbara's Memorial Nursing Home | 2.7 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.