Pierpont Center At Fairmont Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairmont, West Virginia.
- Location
- 1543 Country Club Road, Fairmont, West Virginia 26554
- CMS Provider Number
- 515155
- Inspections on file
- 26
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 18
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.
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.
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.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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