Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Summersville Healthcare Center during CMS and state inspections, most recent first.
Incorrect Tracheostomy Inner Cannula Size Used During Care: An RN performed trach care for a resident and initially tried to insert a 6.5 mm inner cannula that did not fit fully into the trach tube. After another RN checked the order, the correct 5.5 mm inner cannula was obtained and inserted easily. The resident’s order specified daily and PRN trach care with a Shiley cuffless size 4 trach and a 5.5 mm inner cannula.
Failure to document pain levels for PRN analgesic administration. A resident with a BIMS of 12 received PRN Hydrocodone-Acetaminophen via G-Tube 43 times, and for 27 administrations the MAR did not show a pain level. The resident stated they could tell staff their pain level, and the DON confirmed the pain levels were not documented.
An expired bottle of magnesium tablets, 500 mg, was found in a second-floor med storage room during an inspection with an RN present. The facility policy stated out-of-date meds would be discarded, and the RN confirmed the medication had expired.
The facility failed to provide palatable and appetizing meals, as reported by several residents who described the food as mediocre, awful, and not good. Complaints included late meals, lack of drinks and silverware, tough meat, and cold or incomplete meals. A test tray evaluation confirmed these issues, with surveyors finding the meals unappetizing and poorly presented.
The facility did not ensure the cleanliness of kitchen equipment, as observed during a kitchen tour where the oven was found with grease and food spillage. The Culinary Director admitted the oven was cleaned weekly or bi-weekly, but acknowledged it should be cleaned upon noticing spillage.
The facility failed to follow physician orders for two residents with mastectomies by taking blood pressure in restricted arms multiple times. Additionally, a resident with a history of falls was observed without required fall safety devices, which she frequently removed. The DON acknowledged these lapses in care.
The facility failed to accurately complete POST forms for three residents, leading to deficiencies in maintaining accurate medical records. A resident's gender was incorrectly marked, another resident's form lacked the preparer's signature and date, and a third resident's form had the preparer's name struck out. These issues were identified during record reviews and confirmed through staff interviews.
A facility failed to provide accessible call lights and sufficient equipment for residents. One resident's call light was out of reach, and another missed activities due to unavailable lift equipment. Staff confirmed the issues, citing shared equipment and misplaced lift pads.
A resident was not allowed to leave the facility with her daughter due to the lack of a portable oxygen concentrator, despite having continuous oxygen orders. The facility's staff, including an LPN and the DON, confirmed that there was no safe way to transport the oxygen tanks, preventing the resident from exercising her right to self-determination. The resident felt imprisoned, and her daughter noted her disappointment.
A resident reported not receiving mail on Saturdays, including church bulletins, which were typically delivered on Mondays. The Activities Director admitted that mail was sometimes left under a ledge and not delivered. Facility policies confirm residents' rights to privacy in mail communication.
Two residents had blood pressures taken in restricted arms despite care plans indicating otherwise. One resident's care plan specified no blood pressures on the left arm due to a mastectomy, yet it was done ten times over three months. Another resident had a similar restriction, but blood pressures were taken 58 times in the left arm. The DON and an LPN acknowledged these actions.
A facility failed to ensure a hazard-free environment by allowing a resident to keep artificial tears at the bedside without a physician's order. The medication was observed during an interview, and a review of records confirmed the absence of an order. A nurse aide was unaware of the medication, and the DON confirmed it should not have been there.
A resident's POST form was improperly signed by the MPOA despite the resident having the capacity to make their own medical decisions. The form, which included directives like No CPR and Selective Treatments, should have been signed by the resident. This was confirmed by a Physician's Determination of Capacity and acknowledged by the DON.
A facility failed to implement proper infection control procedures when a resident's room, marked for droplet precautions, was found with the door open. An LPN acknowledged the oversight and closed the door after being informed. This incident highlights a deficiency in maintaining infection control protocols.
Incorrect Tracheostomy Inner Cannula Size Used During Care
Penalty
Summary
The facility failed to perform tracheostomy care within accepted standards of care for Resident #3. The resident had physician’s orders written on 12/04/25 for daily and as-needed trach care, including cleaning the stoma and flange, changing the drain sponge, and changing the disposable inner cannula. The orders also specified a Shiley cuffless size 4 trach with a 5.5 mm inner cannula. During observation on 04/29/2026 at 10:15 AM, RN #83 performed tracheostomy care and removed the inner cannula. After cleaning around the tracheostomy site, RN #83 attempted to insert a replacement inner cannula, but it would not slide fully into the tracheostomy tube and she withdrew it after feeling resistance. RN #83 first obtained another 6.5 mm inner cannula from RN #111, but when the surveyor asked RN #111 to check the physician’s order, RN #111 returned with a 5.5 mm inner cannula and stated that was the ordered size. RN #83 then easily inserted the 5.5 mm inner cannula into the resident’s tracheostomy tube.
Failure to Document Pain Levels for PRN Analgesic Administration
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident who required PRN pain medication by not documenting the resident’s pain level when Hydrocodone-Acetaminophen 7.5-325 mg via G-Tube was administered every 6 hours as needed for pain. Record review showed the PRN medication was given 43 times, and for 27 of those administrations, no pain levels were recorded in the medical record. The resident’s MDS with an ARD of 03/09/26 showed a BIMS score of 12, and the resident stated during interview that they could tell staff what level of pain they were having. The DON confirmed that pain levels were not indicated for the resident’s PRN pain medication administrations.
Expired Medication Found in Floor Stock Cabinet
Penalty
Summary
The facility failed to ensure medication storage met accepted standards of practice when an expired bottle of magnesium tablets, 500 mg, was found in the second floor medication storage room. Review of the facility policy titled "Stock Medications" stated that medications would be discarded when out of date, but the policy had no implementation date listed. During an inspection of the second floor medication storage room with RN #111 present, the expired bottle was observed in the floor stock medication cabinet, and RN #111 confirmed that the medication had expired. The finding was identified during a random opportunity for discovery and involved Resident Identifier #3.
Deficiency in Meal Quality and Presentation
Penalty
Summary
The facility failed to provide meals that were palatable and appetizing, as observed during a survey. Multiple residents expressed dissatisfaction with the food quality, describing it as mediocre, awful, and not good. Specific complaints included meals being late, lack of drinks and silverware, tough meat, and cold or incomplete meals. One resident mentioned receiving a hot dog on a plate with nothing else, while another noted receiving a bun without meat. These issues were reported by several residents, indicating a widespread problem affecting more than a limited number of residents. A test tray evaluation conducted by surveyors further confirmed the residents' complaints. The main meal and alternate meal options were found to be unappetizing, with pork chops described as tough to cut and chew, and side dishes like whipped sweet potatoes, mashed potatoes, and carrots lacking flavor. Additionally, the cornbread was served soggy due to being placed in gravy. An interview with the Culinary Director revealed that cornbread is usually served separately to avoid such issues, suggesting a lapse in standard serving procedures.
Failure to Maintain Cleanliness of Kitchen Equipment
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards for equipment used in food preparation, specifically the oven. During a kitchen tour, surveyors observed that the oven had grease covering its windows and spillage inside, with pieces of food on the oven floor. The Culinary Director (CD) acknowledged that the oven was cleaned once a week or every two weeks, but admitted that it should be cleaned upon noticing spillage, which was not done in this instance.
Non-Compliance with Physician Orders for Blood Pressure Checks and Fall Safety Devices
Penalty
Summary
The facility failed to adhere to physician orders regarding blood pressure checks for two residents who had undergone mastectomies. Resident #28 had a specific order to avoid blood pressure measurements in her left arm due to a mastectomy, yet records showed that blood pressures were taken in the restricted arm 58 times over a period of approximately six weeks. This was confirmed by an LPN who acknowledged taking the blood pressure in the left arm. Similarly, Resident #24 had a physician's order prohibiting blood pressure measurements in the left arm, but records indicated that this order was violated 10 times over three months. Additionally, the facility did not comply with physician orders for fall safety devices for Resident #88, who had a history of repeated falls. The resident was observed without her lumbar sacral support and hipsters while in her wheelchair, despite orders for these devices to be worn. The resident expressed a dislike for the devices and was known to remove them. A unit nurse initially believed the lumbar sacral support was to be used as needed, but later confirmed it was not ordered PRN. The Director of Nursing acknowledged the non-compliance with the physician's orders for all three residents. The repeated failure to follow specific medical directives for blood pressure monitoring and fall prevention devices highlights significant lapses in the facility's adherence to prescribed care plans, potentially compromising resident safety.
Inaccurate Completion of POST Forms
Penalty
Summary
The facility failed to accurately complete Physician Orders for Scope of Treatment (POST) forms for three residents, leading to deficiencies in maintaining accurate medical records. For Resident #14, the POST form incorrectly identified the resident's gender as female, while the resident's profile and admission record indicated the resident was male. This discrepancy was confirmed by the Director of Nursing (DON). For Resident #72, the POST form was missing the preparer's signature and date, which was acknowledged by the DON. In the case of Resident #30, the Social Worker who prepared the form signed it but then struck out her name, resulting in an inaccurate POST form. These issues were identified during record reviews and confirmed through staff interviews.
Deficiencies in Resident Care and Equipment Availability
Penalty
Summary
The facility failed to ensure the call light was accessible to a resident and did not have sufficient equipment to assist another resident in attending activities. In the first instance, a resident in a wheelchair was unable to reach her call light, which was left on the bed. A nurse aide acknowledged the oversight and handed the call light to the resident. The resident's care plan indicated a need for the call bell to be within reach due to her impaired mobility and risk of falls. In the second instance, a resident who required a mechanical lift with two staff assists to transfer was unable to attend a Resident Council meeting and a veterans program because the necessary equipment was unavailable. The resident reported that the lift was shared among residents, and the pads needed for the lift were difficult to locate. A nurse aide confirmed that the facility had only two lifts per floor and that the pads were sometimes hidden by staff, leading to the resident missing her activities.
Facility Fails to Honor Resident's Right to Leave with Oxygen
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing her to leave the facility with her family due to her being on oxygen. The resident, who requires continuous oxygen, was prevented from leaving with her daughter because the facility did not have a portable oxygen concentrator available. The incident occurred when the resident's daughter came to pick her up, and a Licensed Practical Nurse (LPN) informed them that it was against regulations to take the oxygen tanks out of the building. This decision was confirmed by the Registered Nurse Unit Manager and the Director of Nursing (DON), who stated that there was no safe way to transport the tanks. The resident expressed feeling like she was in a prison, and her daughter described her as disappointed and upset after being unable to leave. The facility's policy at the time did not allow residents on oxygen to leave with portable tanks, and the DON confirmed that they were in the process of securing portable concentrators for future use. The facility required residents to give notice if they intended to leave, but spontaneous requests were not accommodated, especially for those on oxygen. The facility's leave of absence policy included a declaration that they were not responsible for events occurring while the resident was on leave.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure the right to private communication for Resident #74 by not delivering mail on Saturdays. During a Resident Council meeting, Resident #74 reported that he did not receive mail on Saturdays, specifically mentioning that he usually received the previous Sunday's church bulletin on Mondays. The Activities Director acknowledged that mail was sometimes left under a ledge on Saturdays and not always delivered to residents. A review of the facility's Policies and Procedures for Resident's Rights confirmed that residents have the right to privacy in sending and receiving mail and email.
Failure to Implement Care Plans for Blood Pressure Monitoring
Penalty
Summary
The facility failed to implement care plans for two residents, resulting in blood pressures being taken in restricted arms. Resident #24 had a care plan indicating no blood pressures or needle sticks should be performed on the left arm due to a history of mastectomy. Despite this, records showed that blood pressure was taken in the restricted arm ten times over three months. The Director of Nursing confirmed that these actions were against the care plan. Similarly, Resident #28 had an order specifying that blood pressures should be taken on the right side due to a mastectomy, and the care plan also indicated no blood pressures or lab draws from the left arm. However, the facility took blood pressures in the left arm 58 times since the beginning of October. An LPN acknowledged taking blood pressures in the restricted arm, and the Director of Nursing was made aware of these instances.
Medication at Bedside Without Physician's Order
Penalty
Summary
The facility failed to maintain an accident and hazard-free environment by allowing medication to be kept at a resident's bedside without a physician's order. During an interview with a resident, a bottle of artificial tears was observed at the bedside. A subsequent observation confirmed the presence of the artificial tears, and a review of the resident's records revealed no physician's order for the medication or permission for it to be kept at the bedside. A nurse aide was unaware of the medication's presence, and the Director of Nursing confirmed that the artificial tears should not have been at the bedside and that there was no physician's order for them.
Improper Signing of POST Form by MPOA
Penalty
Summary
The facility failed to ensure that the appropriate party signed the Physician Orders for Scope of Treatment (POST) form for a resident who had the capacity to make their own medical decisions. The review of the resident's records showed that the POST form was signed by the Medical Power of Attorney (MPOA) instead of the resident, despite a Physician's Determination of Capacity indicating that the resident demonstrated capacity. The POST form, which included directives such as No CPR, Selective Treatments, and No artificial means of nutrition, was signed by the MPOA when the resident was capable of signing it themselves. This discrepancy was acknowledged by the Director of Nursing (DON) during an interview.
Infection Control Breach: Droplet Precautions Not Followed
Penalty
Summary
The facility failed to properly implement infection control procedures, specifically in maintaining droplet precautions for a resident. During an observation, a sign indicating droplet precautions, including the instruction to keep the door closed, was noted on the door of a resident's room. However, the door was observed to be open. A Licensed Practical Nurse (LPN) acknowledged the oversight and admitted to missing the precaution, subsequently closing the door. This lapse in following infection control protocols was identified as a deficiency during the survey.
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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 Summersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Webster Healthcare Center | 16.9 mi | ★★★★★ | 6 | 0 |
| Ansted Center | 18.4 mi | ★★★★★ | 19 | 0 |
| Fayetteville Healthcare Center | 22.1 mi | ★★★★★ | 4 | 0 |
| Rainelle Healthcare Center | 23.6 mi | ★★★★★ | 6 | 0 |
| Clay Healthcare Center | 24.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.