Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Tygart Center At Fairmont Campus during CMS and state inspections, most recent first.
The facility did not maintain a clean, comfortable, homelike environment for several residents. In one room, the PTAC unit’s filters were observed to be fully covered with about two inches of dust and debris; a housekeeper confirmed they were dirty, and the maintenance director acknowledged there was no written policy or schedule for cleaning these units. In another room, the wall behind the bed and beside the headboard had multiple scratches with missing paint, which an LPN confirmed. These environmental issues were identified during the survey and had the potential to affect more than a limited number of residents.
Surveyors identified multiple failures in infection prevention and control, including an activities assistant entering a COVID-positive resident’s room without PPE despite droplet precaution signage, staff not offering hand hygiene to several residents during meal tray delivery and setup, and an employee carrying a resident’s plate with a thumb inside the food barrier. The laundry room exhaust system did not maintain proper airflow from clean to soiled areas as required by facility policy. Additionally, doors to COVID-positive rooms were left open contrary to the facility’s Special Contact and Droplet Precautions policy, and an OT was observed providing care to a COVID-positive resident without required eye protection.
The facility did not ensure that all staff received required education on the risks and benefits of the COVID-19 vaccine or that this education was documented. Review of the HealthStream education system for several CNAs showed no records of COVID-19 vaccine education. The Infection Preventionist RN reported that she only provided COVID-19 vaccine information when staff requested it and confirmed there was no related education module in the HealthStream system. This deficiency had the potential to affect more than a limited number of the 106 residents.
Failure to follow ordered care and treatments for multiple residents. A resident with dysphagia orders was left unsupervised with food despite 1:1 feed assist and meal supervision orders, another resident had no documentation that ordered splints were applied and removed with skin checks, and a third resident’s tube feeding was observed running at a rate different from the physician order, with the DON confirming the discrepancy.
A nurse poured medications and handed them to another nurse for administration to a resident, which the DON said was not the facility’s practice. In the medication room, an emergency kit labeled REFRIGERATE was found sitting on a cabinet instead of in the refrigerator, and two locked clear plastic boxes containing Ativan were found in a refrigerator but were not permanently affixed.
A facility failed to follow its menu for two residents at lunch. The menu and tray cards listed Salisbury Steak w/ Mushroom Gravy, and one resident’s tray card specified a gravy portion, but an NP confirmed there was no gravy on either resident’s meat served.
Improper food storage and unclean kitchen areas were observed in the kitchen and nourishment pantry. The DM acknowledged covered desserts without labels or dates, an employee salad in the cooler, an unlabeled employee Pepsi in the refrigerator, and a torn peanut butter packet exposed to air. Staff also found residue in utensil drawers, spilled coffee grounds and liquids on the floor, dusty sugar and flour bin lids with product spilled on the floor, and nonfood items such as an employee cup, toiletries, a seat cushion, and gloves stored in the nourishment room cabinets.
Improper Disposal of Garbage and Refuse: During an observation of the dumpsters, trash and debris were scattered around and behind both dumpsters, including plastic gloves, cup lids, Styrofoam cups, plastic bags, an open take-out food box, and a clear bag of trash on the ground. The DSME stated he had seen the debris around the dumpsters.
The facility failed to ensure its QAA committee met at least quarterly with the required minimum members. Review of sign-in sheets showed the DON did not attend the 2nd or 3rd quarter meetings, and neither the DON nor ADON attended the QAA meetings for the 2nd and 3rd quarter of 2025. The Administrator stated the facility was between DONs and later confirmed there was no DON or ADON in attendance for those meetings.
A resident’s annual MDS incorrectly indicated insulin use in Section N. Review of the physician orders and MAR found no insulin order and no insulin administration, and the MDS Coordinator confirmed the section was marked incorrectly.
PASARRs were missing current diagnoses for two residents. One resident’s Schizophrenia and another resident’s Epilepsy, including treatment with Lacosamide, were not listed on the most recent PASARRs, and the LSW confirmed the omissions during interview.
A resident with orders for 1:1 feed assist and supervision at meals was left unsupervised for 8 minutes after tray setup, and staff acknowledged the ordered supervision was not followed. Another resident reported hearing difficulty and use of hearing aids, but the chart and care plan did not address auditory needs; staff were unaware of the hearing issue until the resident could not hear what was being said and a hearing aid was found in only one ear.
Care plans were not revised for two residents. One resident’s care plan still reflected antibiotic treatment for a UTI even though the one-time Fosfomycin order had been discontinued, and another resident’s advance directive care plan still listed full code despite a change to DNR. The DON confirmed both care plans were not updated to match the current orders and code status.
A resident had a suction machine at the bedside with no canister attached, and a nurse aide confirmed the canister was missing. Surveyors also observed a package with sterile catheter supplies hanging on the bedside table. The DON and Nurse Educator stated they do not set up the suction machines except the sterile equipment, and the Nurse Educator said they were looking at getting the order discontinued.
PASARRs were not kept current and accurate for two residents. One resident’s PASARR did not reflect a diagnosis of vascular dementia with anxiety, and the DON acknowledged facility-wide PASARR updates were needed. Another resident’s PASARR indicated discharge within 90 days, but the resident remained in the facility, and the SW stated the PASARR was not current.
Call lights were not kept within reach for two residents. An NP observed one resident’s call light not within reach and placed it there, while an LPN confirmed another resident’s call light, TV remote, and bed remote were on the floor and not accessible. The facility policy stated staff will ensure the call light is within reach and secured as needed.
The facility did not accurately post daily nurse staffing information, with discrepancies found between posted hours and actual hours worked for RNs, LPNs, and Certified Nurse Aides on most days reviewed. The DON was unable to explain the differences when questioned.
Surveyors observed mature gnats swarming around the kitchen drain area, and the district manager confirmed that although an exterminator had been contacted for advice, the facility had not yet been treated for the pest issue.
Surveyors found that several residents' rooms had dirty, stained privacy curtains and bathrooms in disrepair, including exposed screws and unfinished drywall. Staff and the DON acknowledged these issues during interviews.
Surveyors found that the facility did not consistently provide complete transfer and bed hold notices or notify the Ombudsman as required when residents were transferred or discharged. In several cases, forms were incomplete or missing, and notifications to residents, their representatives, and the Ombudsman were not documented, as confirmed by facility leadership.
Two residents experienced inadequate pain management due to delays in medication administration, improper documentation, and lack of follow-up on pain relief effectiveness. Nursing staff failed to document pain medication administration on the MAR and did not assess or record the effectiveness of PRN pain medications as required, resulting in unmet pain needs.
Several residents reported that meals were unpalatable, lacked seasoning, were sometimes served cold, and did not include fresh produce. Surveyors confirmed these concerns by tasting a meal and finding items overcooked, unseasoned, and one item below the required serving temperature.
Staff failed to reheat food to the required temperature before serving, did not follow proper hand hygiene when serving drinks, and neglected to wear appropriate hair and beard coverings in the kitchen. Additionally, staff personal items were found stored in a nourishment room alongside resident food items, contrary to posted policies.
Surveyors found that two residents had unopened nutritional supplements at the nurses' station, even though the MAR indicated they had consumed them, and a nurse admitted the records should have shown the supplements were refused. Another resident's records showed conflicting information between a physician's order for G-tube feeding and a nursing evaluation stating the resident was eating orally, though staff confirmed all nutrition was via G-tube.
A registered nurse compromised infection control during wound care by touching her glasses and allowing a nurse aide to place a bath basin on the sterile field. A nebulizer and mask were found stored on the floor next to a resident's bed, and another resident's wheelchair had a torn back rest exposing inner padding. Staff acknowledged these breaches upon observation and interview.
Two residents did not receive care in accordance with physician orders and facility policy: one resident continued to receive wound care after the wound had healed, and another did not have required neuro checks documented after a fall. The DON and RN confirmed these lapses in care.
A resident was not asked about their food preferences upon admission, did not receive information about available menu options, and had no food preferences documented in their care plan. Staff interviews confirmed that required procedures for gathering and honoring food choices were not followed, resulting in the resident receiving meals without consideration of their preferences.
A nurse told a resident she could not receive her PRN Tylenol for pain until she ate half her meal, despite no such order, and only administered the medication after staff intervention. The incident, which constituted an allegation of mental/emotional abuse, was not reported to state agencies within the required time frames, in violation of the facility's abuse prohibition policy.
A nurse told a resident she could not receive her as-needed Tylenol for arm pain until she ate at least half of her food, despite no such order in the medical record. The medication was only given after staff intervention following a surveyor's report. Facility leadership confirmed the incident was not reported to state agencies as required.
Surveyors found that the facility did not develop or update care plans for three residents, including a dialysis patient with a new AVF, a resident with bilateral knee contractures, and another whose care plan was incomplete and missing details on required assistance for daily activities. The DON confirmed these omissions during interviews.
A resident's care plan was not revised to reflect a change in code status, as the POST form indicated DNR and comfort measures only, but the care plan still listed the resident as full code. The DON confirmed the care plan had not been updated.
A resident requiring hemodialysis did not receive complete and documented dialysis care, as several Hemodialysis communication sheets were missing or incomplete, and there was no care plan or physician order to monitor a newly placed AVF as requested by the hospital. Additionally, the resident was served meals containing restricted items such as tomatoes and oranges, despite a documented diet order and her stated preferences.
A resident receiving Mirtazapine for depression did not have a timely physician response to a pharmacist's recommendation for gradual dose reduction, as required by facility policy. The pharmacist also did not identify the need for a further GDR after the last review, and the DON confirmed that no additional reviews were completed as scheduled.
A nurse aide did not complete the required 12 hours of annual education, having only 9 hours and 34 minutes documented, including limited dementia care training. No additional education records were provided when requested by the DON.
Two residents who were dependent on staff for ADL care did not receive regular showers or bed baths as required, with one resident going seven days without bathing and another not receiving a shower for 18 days, despite documented preferences and care plans indicating the need for assistance. The DON confirmed the lack of bathing during these periods.
A resident who required a sit-to-stand lift was transferred using a gait belt by a NA, contrary to the care plan, resulting in a laceration that required emergency treatment and stitches. Investigation confirmed the improper transfer method and substantiated neglect, with the issue found to be isolated to this resident.
A resident with limited mobility and incontinence reported that some staff were rough during incontinence care, specifically pulling on her leg too hard. Although the facility indicated staff education would be provided following the abuse allegation, there was no evidence of follow-up education, as confirmed by the DON.
A resident was discharged after unauthorized narcotics were found in her room, but the facility failed to ensure a safe and orderly transition. The resident was referred to a homeless shelter that could not accommodate her physical limitations, resulting in her remaining in a transport vehicle while staff searched for alternatives. Ultimately, the resident chose to be dropped off at a public location, and APS was notified. Facility leadership confirmed the discharge was not handled safely or appropriately.
A resident with a central venous access device did not have a comprehensive, person-centered care plan addressing the care of the device. Although the facility had protocols for catheter care and infection prevention, these were not incorporated into the resident's individualized care plan, as confirmed by the DON and Administrator.
A resident with a central venous access device did not have the required transparent dressing changes performed or documented, as mandated by facility policy and standard practice. Although the central line was not used for medication administration, it remained in place without evidence of dressing changes throughout the resident's stay, as confirmed by record review and staff interviews.
Failure to Maintain Clean PTAC Filters and Proper Wall Conditions in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents, as evidenced by environmental deficiencies identified during the survey. In one resident’s room, observation of the Packaged Terminal Air Conditioner (PTAC) unit showed both filters were fully covered with approximately two inches of dust and debris. A housekeeper filling in from another building confirmed the PTAC filters were dirty and needed cleaning, and the Director of Maintenance stated there was no written policy or schedule for cleaning the PTAC units, although he reported they were cleaned monthly. In another resident’s room, the wall behind the bed and on the right side of the headboard had multiple scratches with missing paint, and an LPN confirmed the walls were in this condition. These conditions were identified as part of the Long-Term Care Survey Process and had the potential to affect more than a limited number of residents. No additional medical history or clinical conditions of the residents involved were provided in the report.
Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including improper use of PPE, inadequate hand hygiene practices, and noncompliance with transmission-based precautions. Surveyors observed an activities assistant entering the room of a resident on droplet precautions, with COVID-19 signage and a red stop sign on the door, without wearing any PPE, while other staff in the room were properly donned. The assistant initially stated the resident did not “have anything” and had been going to the dining room without a mask, and only acknowledged the need for PPE after being informed the resident had COVID-19. During meal tray delivery and setup on one hall, the admissions coordinator and another employee did not offer or provide hand sanitizer or other hand hygiene to multiple residents before meals and later acknowledged they had failed to do so. In the dining room, another employee was observed carrying a resident’s plate with his thumb resting inside the plate’s food barrier and admitted his thumb was too far into the plate. Additional deficiencies were identified related to environmental controls and adherence to the facility’s own infection control policies. The facility’s exhaust system policy required monthly inspection of laundry room exhaust fans and verification that airflow was sufficient to hold a piece of paper to the vent; however, during a tissue test in the laundry area, air was not pulling from the clean side to the soiled side as required. The facility’s Special Contact and Droplet Precautions policy required doors of affected residents to remain closed, yet multiple doors to COVID-positive resident rooms were observed open on two halls during the survey, and two COVID-positive room doors were later observed open again, with one nurse reporting that the resident leaves the room wearing a mask. The same policy required staff to wear appropriate PPE, including N95 respirator, gown, gloves, and recommended eye protection for encounters with positive patients, but an occupational therapist was observed inside a COVID-positive resident’s room without any eye protection and stated they did not have a face shield or glasses.
Failure to Provide and Document COVID-19 Vaccine Education for All Staff
Penalty
Summary
The facility failed to ensure that COVID-19 vaccine education was provided to all staff as required by federal guidelines, which mandate that staff receive education on the risks and benefits of the vaccine and that the vaccine be offered by the facility or that information be provided on how to obtain it. Surveyors reviewed the HealthStream education records for five nursing assistants and found no documentation of COVID-19 vaccine education. During an interview, the Infection Preventionist RN stated that she only provided COVID-19 vaccine information to staff if they requested it and confirmed that there was no COVID-19 vaccine education content in the HealthStream system. This failure had the potential to affect more than a limited number of the facility’s 106 residents. No specific residents, their medical histories, or conditions at the time of the deficiency were described in the report.
Failure to Follow Ordered Care and Treatments
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with current standards of practice for multiple residents. Resident #30 had physician and care plan orders for a regular dysphagia pureed diet with thin liquids, 1:1 feed assist, and supervision for all meals. During a dining room observation, staff retrieved the resident’s tray, assisted with set-up, handed him his sandwich, and then left him with food unsupervised for 8 minutes. The staff member acknowledged leaving the resident to eat by himself without supervision, and the Corporate Coordinator acknowledged that the physician orders for 1:1 feed and supervision for all meals were not followed. Resident #80 had orders for multiple contracture management devices, including right elbow extension splint, left elbow extension splint, right resting hand splint, and left palm protector, each to be donned for 2 hours on specified days with skin checks. Review of the MAR, TAR, Kardex, and tasks found no documentation that the splints were applied or removed with skin checks as ordered, and the DON stated there was nothing showing they were donned and doffed. Resident #11 had a tube feeding order for Jevity 1.5 cal to run via pump at 60 ml per hour for 20 hours daily, but observations showed the pump and bottle set at 55 ml per hour on two occasions. The DON confirmed the pump was set at 55 ml while the order read 60 ml and stated the dietician had changed the order to 55 ml for 12 hours before it was moved back to 60 ml, creating confusion.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to store and administer medications according to professional standards of practice. On 02/12/26 at 8:25 AM, RN #81 was observed pouring medications for a resident and then handing the poured medications to LPN #72, who administered them to the resident. When asked why she poured the medications and gave them to the LPN to administer, RN #81 stated that she watched the medications being poured. The DON later stated that it was not the facility’s practice for one nurse to pour medications and another nurse to administer them. During the same observation in the 200 Hall medication room, an emergency kit with an orange label reading REFRIGERATE was found sitting on the cabinet, and RN #81 could not explain why it was not in the refrigerator. Also in Medication Refrigerator Two, two locked clear plastic boxes containing Ativan were found in the lower box, and the boxes were not permanently affixed in the refrigerator, which RN #81 confirmed.
Menu Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure menus were followed. The facility’s policy stated that menus would be served as written unless a substitution was provided for preference, unavailability of an item, or a special meal. The menu provided to the state surveyor listed Salisbury Steak with Mushroom Gravy for lunch on Monday 02/09/26 for regular, dysphagia advanced, and puree diets. Tray cards for Resident #40 and Resident #63 also listed Salisbury Steak w/Mushroom Gravy, and Resident #40’s tray card specified gravy-#10 scoop for the Ground Meat Salisbury Steak. However, Nurse Practitioner #24 confirmed that there was no gravy on both residents’ meat served at lunch.
Improper Food Storage and Unclean Kitchen Areas
Penalty
Summary
Food was not properly stored in accordance with professional standards in the facility kitchen and nourishment pantry. During an initial brief tour, the Dietary Account Manager acknowledged multiple storage and sanitation issues in the walk-in cooler and kitchen areas, including a shelved food cart of desserts that were covered but not labeled or dated, a salad marked with a name that the Dietary Account Manager identified as belonging to an employee and removed, and an unopened bottle of Pepsi in the 200 Hall refrigerator that also lacked a label or date and was discarded by the Dietary Account Manager. In the upper cabinet, a packet of peanut butter was observed with a tear in the cover exposing the peanut butter to air. Additional observations showed poor organization and cleanliness in food storage and preparation areas. The top utensil drawer had a powdery white residue on the inside bottom under the utensils, the bottom drawer had utensils scattered and not facing the same direction, and coffee grounds and brownish spilled liquid spots were observed on the kitchen floor in front of the shelves, tray line, and stove. Sugar and flour bin lids were dusty with flour and sugar spilled onto the floor, and the Dietary Account Manager stated the floors should have been cleaned the night before but did not have a cleaning schedule or sign-off sheets. In the nourishment room, a large plastic cup with a lid and straw was found in a cabinet and identified as belonging to an employee, and two boxes containing toiletries, a donut-shaped seat cushion, and a large case of plastic gloves were found in a bottom cabinet shelf; the Corporate Coordinator stated these items were not supposed to be there and removed them.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not disposed of properly. During an observation of the dumpsters, debris and trash were seen scattered around and behind both dumpsters. Plastic gloves, plastic cup lids, Styrofoam cups, and plastic bags were observed in the front and sides of both the right and left dumpsters. An opened box containing take-out food was left open, and a clear bag of trash was laying on the ground on the left side of the left dumpster. In interview, the Director-Senior Maintenance Employee stated he had seen the trash and debris scattered around the dumpster and would get it taken care of.
QAA Committee Did Not Meet Required Membership
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly with the required minimum staff. Review of QAA sign-in sheets from 01/25 to 01/26 showed that the DON did not attend the 2nd quarter or 3rd quarter meetings, and further review showed that neither the ADON nor the DON attended the QAA meetings for the 2nd and 3rd quarter of 2025. During interview, the Administrator stated that the facility had the ADON filling in as DON because the facility was between DONs, and later confirmed that there was no DON or ADON in attendance for those QAA meetings. Review of the facility policy titled Quality Assurance and Performance Improvement Plan stated that the committee must include the DON, IP, Medical Director or designee, and three additional team members, one of whom is the Administrator, with a consultant pharmacist recommended.
Incorrect MDS Documentation of Insulin Use
Penalty
Summary
Section N of the annual MDS for Resident #16 was completed inaccurately. During review of the annual MDS with an ARD of 12/29/25, Section N indicated the resident was receiving insulin, but a review of the current physician orders and MAR did not show an order for insulin or any insulin administration. The MDS Coordinator confirmed during interview that Section N had been marked incorrectly.
PASARRs Missing Current Diagnoses
Penalty
Summary
The facility failed to include all appropriate diagnoses on the most recent Pre-admission Screening and Resident Review (PASARR) for 2 of 5 residents reviewed for PASARR accuracy. One resident had a current diagnosis of Schizophrenia with a start date of 10/30/25, but the most recent PASARR completed on 05/02/22 did not indicate Schizophrenia in section 30 or anywhere else on the form. Another resident had a current diagnosis of Epilepsy and was being treated with Lacosamide oral tablet 100 mg twice daily, but the most recent PASARR completed on 04/02/25 did not indicate Epilepsy in section 30 or anywhere else on the form. During interview, the LSW confirmed both diagnoses were missing from the PASARR and stated, "We just missed it."
Failure to Follow Meal Supervision Orders and Address Hearing Needs in Care Plans
Penalty
Summary
The facility failed to develop and/or implement care plans related to physician dietary orders and auditory needs for two residents. Resident #30 had physician orders and a meal ticket indicating a 1:1 feed assist and supervision for all meals, and the care plan stated the resident was receiving a regular dysphagia pureed diet and thin liquids with 1:1 supervision at meals. During a dining room tray pass, the resident’s tray was set up by Employee #17, who then left the resident unsupervised for 8 minutes while retrieving another resident’s tray. In interview, Employee #17 acknowledged leaving the resident to eat by himself without supervision, and the Corporate Coordinator acknowledged the physician orders for 1:1 feed and supervision for all meals were not followed. Resident #104 stated she was not able to hear and had difficulty communicating, and said she had two hearing aids that did not work well. Record review found no mention of her auditory needs or hearing aids in the physician orders or care plan. During observation, Employee #81 was talking very loudly to the resident and stated she was not aware of the resident’s hearing trouble, saying, "She seems to hear me ok." When asked in the presence of Employee #81, the resident stated she was not able to hear what was being said. Employee #81 then discovered a hearing aid in the resident’s left ear but nothing in the right ear, and the DON acknowledged the care plan failed to include the resident’s auditory needs.
Care Plans Not Updated for Discontinued Antibiotic Order and DNR Status
Penalty
Summary
The facility failed to ensure that care plans were revised for discontinued physician orders and for resident advance directive status. For Resident #4, the care plan stated the resident was receiving antibiotic treatment for a urinary tract infection and included an intervention to administer medications as ordered, with the care plan initiated on 01/21/26. However, record review showed the antibiotic order could not be found in the chart, and the DON later provided the discontinued physician order for Fosfomycin Tromethamine 3 GM, one packet by mouth one time only for UTI, confirming that the care plan had not been revised to reflect that the antibiotic treatment had been discontinued. For Resident #11, record review showed the resident’s code status had been changed from full code to DNR on 02/02/26, but the current advance directive care plan still stated full code and had a revision date of 01/06/26. The DON confirmed that the care plan did not reflect the resident’s current code status.
Suction Equipment Left Incomplete at Bedside
Penalty
Summary
The facility failed to ensure Resident #80’s environment remained as free of accident hazards as possible when suction equipment was left at the bedside without a canister attached. During the initial interview on 02/09/26 at 2:00 PM, the resident had a suction machine on the bedside table, but no canister was in the machine or located around it. At 2:05 PM, Nurse Aide #3 verified that there was no canister in the suction machine. Additional observations during the survey found a package containing a sterile catheter, container, and gloves hanging on the resident’s bedside table. On 02/11/2026, the Nurse Educator reported they were looking at getting the order discontinued for the suction machine, and the DON and Nurse Educator stated they do not set up the suction machines except the sterile equipment.
PASARRs Not Kept Current for Two Residents
Penalty
Summary
The facility failed to ensure that two residents’ PASARRs were current and accurate. Resident #67 had a diagnosis of vascular dementia, moderate, with anxiety, but the PASARR was not updated to reflect that diagnosis. During interview, the DON acknowledged that Resident #67’s PASARR had not been updated because of the vascular dementia diagnosis and stated that PASARRs facility-wide were in need of updating. Resident #16 had a PASARR dated 12/23/24 that indicated the resident would eventually return home or be discharged in less than three months, with the physician specifying 90 days, but the resident remained in the facility. The SW stated that Resident #16’s PASARR was not current because the resident was still in the facility.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. For Resident #40, the policy for call lights stated that staff will ensure the call light is within reach and secured as needed, but on 02/09/2026 at 12:45 PM the resident’s call light was observed not to be within reach. A Nurse Practitioner confirmed the call light was not in reach, unwrapped it from the bedrail, and placed it within the resident’s reach. For Resident #50, on 02/02/26 at 12:30 PM the resident’s call light, TV remote, and bed remote were observed on the floor, and after the lunch tray was passed, the items remained on the floor beside the bed at 1:05 PM. An LPN confirmed the call light was on the floor and not within reach and stated, “I’m sorry.” The policy for call lights stated that staff will ensure the call light is within reach of the patient and secured as needed.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to provide accurate daily postings of nurse staffing information, as required. During the annual survey, a review of nursing staffing data and time and attendance reports for 15 selected days revealed discrepancies on 14 days, where the posted nurse staffing hours for RNs, LPNs, and Certified Nurse Aides did not match the actual hours worked according to time and attendance records. For example, on several dates, the posted hours were significantly higher than the hours documented in the attendance system. When these inconsistencies were presented to the Director of Nursing, no explanation was provided for the differences.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mature gnats swarming around the drain area under the dishwasher table in the dish room side of the kitchen. This observation was made during a walk-through, and the issue was acknowledged by the district manager, who stated that although the exterminator had been contacted for advice a week prior, the facility had not yet been treated for the gnats. The deficiency was identified as a random opportunity for discovery and had the potential to affect multiple residents, with a facility census of 106. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment in several resident rooms. Specifically, privacy curtains in multiple rooms were found to be dirty and stained, with one resident identifying a stain as vomit. Staff interviews confirmed awareness of the issue, with an LPN acknowledging that the curtain required cleaning and describing the usual process for notifying housekeeping when such issues are noticed. Additional observations revealed that several resident bathrooms were not in good repair. Issues included screws protruding from drywall, unfinished drywall patches, and general disrepair in the bathroom areas of multiple rooms. During a walkthrough, the DON acknowledged these maintenance issues in the identified rooms.
Failure to Provide Required Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
Surveyors identified that the facility failed to provide required documentation and notifications related to resident transfers, discharges, and bed-hold policies for multiple residents. Specifically, for several residents who were transferred to hospitals or went on therapeutic leave, the facility did not complete or provide adequate Notice of Transfer, Bed Hold Notices, or notifications to the Office of the State Long-Term Care Ombudsman. In several instances, the forms were incomplete, missing critical information such as the number of bed-hold days remaining, the reason for transfer, or the names of individuals notified. Some forms were only partially filled out, with staff signing in multiple required signature spaces or failing to document verbal notifications appropriately. In addition, there was no evidence that the required notifications were sent to the Ombudsman, as confirmed by facility leadership during interviews. The deficiency was found across multiple resident records reviewed during the annual survey, with five out of six records lacking proper documentation and notification. The facility's Person In Charge and DON confirmed the absence of required notifications and attributed some missing documentation to lost records during an office move. The failures included not notifying residents and their representatives in writing and in a manner they could understand, as well as not sending copies of transfer or discharge notices to the Ombudsman, as required by regulation.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to the administration and documentation of pain medication. One resident reported experiencing significant pain, rating it as an eight out of ten, and stated she had been requesting pain medication without receiving it. The nurse on duty initially withheld the medication due to a misunderstanding of the dosing interval, only contacting the physician to adjust the order after the resident's continued complaints. Documentation review revealed discrepancies between the controlled substance log and the Medication Administration Record (MAR), with several instances where pain medication was signed out but not documented as administered on the MAR, and no evaluation of the medication's effectiveness was recorded as required by facility policy. Another resident, admitted for therapy following an unrepaired hip fracture, also reported ongoing pain and concern about participating in therapy due to inadequate pain control. Review of her medical records showed multiple changes in pain medication orders, but again, there were instances where pain medication was signed out on the controlled substance log without corresponding documentation on the MAR or evaluation of effectiveness. The DON was unable to provide documentation for a reported refusal of alternative pain medication and made comments regarding the resident's pain tolerance without supporting evidence. Both cases demonstrate failures to follow professional standards of practice, the comprehensive care plan, and the residents' choices regarding pain management. The lack of proper documentation and timely administration of pain medication, as well as failure to assess and record the effectiveness of pain interventions, contributed to the deficiency identified during the survey.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that resident meals were palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported that the food was unappealing, lacked taste, was sometimes served cold, and did not include fresh fruits or vegetables. One resident stated she was supposed to receive yogurt with every meal but often did not. Residents also indicated they were not informed about an always available menu. During a meal observation, surveyors found that the macaroni and cheese and broccoli were overcooked and unseasoned, and the temperature of the fried potatoes was below the required standard at 113 degrees Fahrenheit. These findings were based on direct resident interviews and surveyor meal tasting, indicating a pattern of inadequate food quality and service.
Multiple Food Safety and Sanitation Deficiencies Identified
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in multiple instances. During a noon meal service, a staff member reheated broccoli that had previously fallen below the safe holding temperature, but only reheated it to 160°F before serving, despite the requirement to reheat to 165°F. The Dietary Account Manager incorrectly advised that 160°F was acceptable, and the corporate account manager later confirmed the error. Additionally, during a dining room observation, an employee served drinks to residents without performing proper hand hygiene after touching residents and objects, which was acknowledged as improper by the person in charge. Further deficiencies were observed in the kitchen, where staff, including the Dietary Account Manager and a cook, failed to wear appropriate hairnets and beard nets, leaving hair exposed while working with food. Staff interviews revealed a lack of awareness regarding the requirements for hair and beard coverings. In the 400 Hall Nourishment Room, staff personal belongings, including drink cups, an open can, a purse, and clothing, were found stored alongside resident nourishment items, despite posted signage prohibiting staff items in these areas. The DON acknowledged that staff personal items should not have been present in the nourishment room.
Inaccurate Documentation of Supplement Intake and Nutrition Status
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records of several residents. For two residents, unopened nutritional supplements (mighty shakes) were observed at the nurses' station in the afternoon, despite the Medication Administration Record (MAR) indicating that both had consumed 100% of their supplements at 10:00 AM. Upon interview, the registered nurse responsible acknowledged that she should have documented the supplements as refused rather than consumed. Additionally, a review of another resident's records revealed inconsistencies between the physician's order and the skilled nursing evaluation. The physician's order specified enteral feeding via G-tube, with the resident marked as NPO (nothing by mouth), yet the skilled nursing evaluation documented that the resident was taking nutrition and hydration orally and showed no signs of swallowing disorder. Corporate nursing staff later confirmed that the resident was receiving all nutrition through the G-tube and not orally.
Infection Control Breaches During Wound Care, Equipment Storage, and Wheelchair Maintenance
Penalty
Summary
During wound care for a resident, a registered nurse repeatedly touched her glasses while performing the procedure and did not realize this action, which compromised infection control standards. Additionally, a nurse aide placed a bath basin of water and wash cloths on the over-the-bed table that was being used as a sterile field for the wound care, further breaching sterile technique. Both staff members acknowledged these actions when interviewed, and the corporate registered nurse confirmed these events as breaches of infection control. In another instance, a nebulizer machine and mask belonging to a resident were observed sitting on the floor next to the resident's bed. The registered nurse supervisor was notified and immediately removed the items from the floor. Additionally, a resident's wheelchair was found to have a tear in the covering of the back rest, exposing the inner padding. Both a nurse aide and the infection control manager acknowledged the condition of the wheelchair, with the infection control manager stating she was previously unaware of its state.
Failure to Discontinue Wound Care and Complete Neurological Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident, after sustaining a fall, the medical record and incident report indicated that neurological assessments were to be completed per policy; however, the facility was unable to provide documentation of these neurological checks when requested, and the DON confirmed the assessments could not be located. For another resident, wound care orders for an abrasion to the left gluteus remained active and were carried out ten additional times after the wound had resolved, as the order was not discontinued when the wound healed. This was confirmed by both the RN responsible and the DON, who acknowledged the treatment should have ended when the wound was resolved.
Failure to Obtain and Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to obtain and honor a resident's food choices, as required by regulations supporting resident self-determination. The resident reported not being asked about their food preferences and stated that meals were provided without consideration of their likes or dislikes. The resident was also unaware of the Always Available menu and had not been informed about it. Interviews with staff revealed that the designated staff member responsible for collecting food preferences within 24 hours of admission had not completed this task, citing workload issues. The staff member also could not explain how the resident would know to request the daily menu or alternative options. A review of the resident's care plan showed that no food preferences were documented, and the facility's policy required dietary staff to visit new residents within 48 hours to introduce meal options and gather preferences. This process was not followed for the resident in question, and the resident was not provided with a Personal Choice Menu. The findings indicate that the facility did not follow its own procedures or regulatory requirements to ensure resident food choices were obtained and honored.
Failure to Report Allegation of Mental/Emotional Abuse as Required
Penalty
Summary
A nurse was observed telling a resident that she could not have her pain medication, Tylenol, until she ate at least half of her food, despite there being no such requirement in the resident's medical orders. The resident expressed that she did not feel like eating because her arm was hurting and confirmed that she had been told she needed to eat to receive her medication. The nurse left the dining room without administering the medication, and the situation was only rectified after intervention by facility staff following the surveyor's report of the incident. A review of the facility's abuse prohibition policy revealed that allegations of mental or emotional abuse are required to be reported to state agencies within specific time frames. However, interviews with the Director of Nursing, Person in Charge, and Corporate RN confirmed that this allegation was not reported as required. The failure to report the incident constituted noncompliance with the facility's own abuse prohibition policy.
Failure to Timely Report Allegation of Mental Abuse
Penalty
Summary
A nurse was observed telling a resident that she could not have her pain medication, Tylenol, until she ate at least half of her food, despite the resident expressing that she did not feel like eating due to arm pain. The resident's medical record indicated no requirement to eat prior to receiving the as-needed Tylenol. The nurse left the dining room without administering the medication, and the resident confirmed she had been told she needed to eat to receive her medicine. Facility staff only intervened and ensured the resident received her medication after the incident was reported by the surveyor. Upon review, facility leadership acknowledged that this allegation of mental abuse was not reported to the required state agencies within the mandated time frames.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, as identified through record reviews, resident interviews, and staff interviews. One resident, who was a hemodialysis patient, had recently returned from the hospital after the placement of an arteriovenous fistula (AVF) in her left upper arm. Despite this significant change in her medical status, her care plan did not include any mention of the AVF, and the DON confirmed that no care plan had been developed for this new condition. Additionally, the resident reported discomfort with her current dialysis port and described her awareness of the AVF, but staff interviews indicated that no specific interventions or monitoring were being performed for the AVF since it was not yet in use. Another resident with bilateral knee contractures did not have these contractures documented in their care plan, a fact confirmed by the DON. A third resident's care plan was found to be incomplete, lacking personalized details regarding the assistance needed for activities such as toileting, transfers, and bathing, with several blanks left unfilled. These findings demonstrate that the facility did not ensure care plans were updated or completed to reflect residents' current needs and conditions.
Failure to Update Care Plan After Change in Code Status
Penalty
Summary
The facility failed to update the care plan for a resident following a change in code status. Record review showed that the resident had a Virginia Physician's Order for Scope of Treatment (POST) form indicating Do Not Resuscitate (DNR), comfort measures only, and no artificial means of nutrition, dated 03/03/25. Despite this, the resident's care plan continued to list the resident as a full code. The Director of Nursing (DON) confirmed during interview that the care plan had not been revised to reflect the updated code status.
Failure to Provide Safe Dialysis Care and Adhere to Dietary Restrictions
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring hemodialysis. Review of the resident's medical record revealed missing and incomplete Hemodialysis communication sheets on several dates, with the post-dialysis section left blank and not completed by nursing staff upon the resident's return from dialysis. This was confirmed by the Director of Nursing. Additionally, after the resident returned from the hospital following the placement of an arteriovenous fistula (AVF), there was no physician order or care plan in place to monitor the AVF for bruit and thrill as requested by the hospital, despite the resident expressing anxiety and requesting monitoring. The facility also failed to ensure the resident's dietary restrictions were followed. The resident had a diet order restricting tomatoes and oranges, yet the menu options provided included tomato products and oranges. During observation, the resident was served a meal containing both restricted items, and she expressed that she did not request those foods. The nurse aide confirmed the contents of the tray and offered to get the resident pudding, which was her preference. The previous Nursing Home Administrator later presented a meal selection sheet indicating the resident had chosen an option that still included restricted items, and did not address the issue when it was pointed out.
Failure to Ensure Timely Physician Response and Pharmacist Review for Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure compliance with its policy regarding timely physician response to pharmacist recommendations for gradual dose reduction (GDR) of an antidepressant medication. Specifically, a resident with a physician's order for Mirtazapine for depression was identified as needing a GDR review by the pharmacist on 12/28/24. However, the attending physician did not provide a response to this recommendation within the facility's required 30-day timeframe. The pharmacist followed up with the physician on 02/27/25, and a response was finally received on 03/05/25, well beyond the policy's deadline. Additionally, the facility did not ensure that the pharmacist identified the need for a possible GDR for the resident after the last documented GDR in May 2024. When asked by the surveyor, the DON confirmed that there were no further GDR reviews after 12/28/24, despite the next review being due in February 2025. No explanation for this lapse was provided before the survey exit.
Failure to Ensure Nurse Aides Complete Required Annual Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of annual education, as evidenced by a review of personnel files during the annual survey. Specifically, one nurse aide was found to have completed only 9 hours and 34 minutes of education in the calendar year 2024, including just 24 minutes of dementia care education. When the Director of Nursing was asked to provide documentation of any additional education for this nurse aide, no further evidence was supplied prior to the survey exit. This deficiency was identified through record review and staff interview, and it was confirmed that the required annual training hours for nurse aides were not met for at least one staff member out of the five files reviewed.
Failure to Provide Assistance with Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, for two dependent residents. For one resident, records showed that no showers or bed baths were provided for a consecutive seven-day period, despite documentation on the Minimum Data Set (MDS) indicating the resident was dependent for these tasks. The Director of Nursing (DON) confirmed the absence of documentation for bathing during this timeframe. Another resident, who expressed a preference for at least one shower per week and indicated that the choice of bathing method was very important to her, did not receive a shower for an 18-day period. The care plan documented that the resident required substantial assistance for personal hygiene due to limited mobility. The DON acknowledged that the resident did not receive showers as frequently as preferred, with only one shower documented during the period in question.
Improper Transfer Procedure Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide (NA) failed to use the appropriate transfer procedure for a resident who required a sit-to-stand lift, as specified in the resident's care plan. Instead, the NA used a gait belt to transfer the resident from a wheelchair to the bed, resulting in the resident sustaining a laceration to the right lower extremity that required emergency room treatment and 16 stitches. The incident was confirmed through the NA's written statement and the facility's investigation, which substantiated neglect. Further review revealed that other NAs may also have been transferring the same resident incorrectly, though a facility-wide audit found the issue to be isolated to this resident. The resident involved was observed to be alert and oriented, using a wheelchair, and did not recall the incident or report any recent falls. The deficiency was identified through record review, interviews, and direct observation.
Failure to Provide Required Staff Education Following Abuse Allegation
Penalty
Summary
The facility failed to provide the required training and education for staff on issues impacting resident care following an allegation of abuse. A resident with limited mobility, pain in her left leg, and incontinence reported that some staff were rough when providing incontinence care, specifically pulling on her leg too hard during diaper changes and linen removal. The resident's care plan indicated she required extensive assistance for personal hygiene and preferred her husband to move her legs during care, but staff interviews revealed her husband was not always present when care was needed. An internal investigation included interviews with other residents, who did not report staff being rough or impatient. Despite the facility's indication in the Facility Reported Incident (FRI) that staff education would be provided on issues impacting resident care, a review of records showed no evidence of follow-up education for staff. The Director of Nursing confirmed the absence of staff education records related to this incident.
Failure to Ensure Safe and Orderly Discharge for Resident with Physical Limitations
Penalty
Summary
The facility failed to provide sufficient preparation and orientation to ensure a safe and orderly discharge for a resident with physical limitations. The resident was notified of a pending discharge due to the discovery of an unauthorized narcotic in her room. The discharge process was initiated quickly, with the resident being informed and paperwork reviewed within a short timeframe. The facility made a referral to a local homeless shelter without confirming that the shelter could accommodate the resident’s physical needs. Upon arrival at the homeless shelter, it was determined that the resident could not be accommodated due to her inability to climb stairs, which was necessary for access to sleeping and dining areas. The facility staff kept the resident in the transport vehicle while attempting to locate another shelter that could accept her. Multiple additional shelters were contacted, but no immediate accommodations were available in the area. Ultimately, the resident requested to be taken to a public location instead of being transported to a shelter further away that had agreed to accept her. The facility complied with her request and made a referral to Adult Protective Services. The facility’s actions did not ensure that the resident’s discharge was safe and orderly, as required, and this was confirmed by facility leadership during interviews.
Failure to Develop Care Plan for Central Line
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had a central venous access device. Record review showed that the resident was admitted with a central intravenous line in the right chest and remained in the facility with the device for several months. Despite the presence of the central line, there was no care plan in place addressing its care. Staff interviews and documentation confirmed that the facility followed pharmacy and internal policies for venous access device care, which included protocols for dressing changes and infection prevention. However, these protocols were not reflected in the resident's individualized care plan, as confirmed by both the Director of Nursing and the Administrator.
Failure to Provide Required Central Line Dressing Changes
Penalty
Summary
A deficiency was identified when a resident with a central venous access device did not receive proper care in accordance with the facility's Infection Prevention Measures Policy and standard practice. The resident was admitted with a central intravenous line in the right chest, and facility policy, as well as pharmacy recommendations, required that the transparent dressing on the device be changed at least every seven days and as needed if the dressing became compromised. However, a review of the Medication Administration Record, Treatment Administration Record, and progress notes from the resident's admission through discharge showed no evidence that the central line dressing was ever changed during the resident's stay. Interviews with the DON and review of documentation confirmed that the central line was never used for medication administration, as the resident received IV antibiotics through a peripheral IV and later a midline IV. Despite this, the central line remained in place, and there was no documentation or evidence of dressing changes as required by policy. The deficiency was confirmed by both the DON and the Administrator, and no additional documentation was provided to show compliance with the required care protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 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) |
|---|---|---|---|---|
| Pierpont 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.