Bridgeport Healthcare Center
41 Crestview Terrace, Bridgeport, WV 26330 · For profit - Corporation · 60 certified beds · (304) 842-7101 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,021 in federal fines (most recent 2024-07-03)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.6% | 14.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.2% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.4% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 9.4% | 7.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.9% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.5% | 15.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.0% | 27.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 97.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.5% | 13.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.2% | 79.4% | 79.4% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
31.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 31.1%CMS range 19.9–44.5 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 6.4–16.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 65.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 13.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.6%CMS range 5.9–17.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 59.4 residents a day — about 99% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.61 on weekdays — 17% thinner on weekends. RN hours go from 0.50 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-07-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible, by having a dysfunctional magnetic lock on the French doors to the outside of the facility through the activities office, exposing residents to hazards that could potentially cause serious injury or death. Resident Identifier: #58. Facility Census: 57. The State agency determined this failure placed the residents in an immediate jeopardy (IJ) situation due to the potential of serious injury and/or death as a result of a documented elopement. The State agency notified the Nursing Home Administrator of the immediate jeopardy at 12:50 PM on 07/02/24. The facility submitted a plan of correction (POC) at 2:42 PM. At 3:42 PM on 07/02/24, the POC was accepted by the State agency. The State agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 10:35 AM on 07/03/24. Findings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-09 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation and interview, the facility failed to maintain a safe, clean homelike environment for residents. This was found to be true in three (3) rooms of eight (8) observed. Room identifiers: #202, #204, #206. Facility census: 59. Findings included: During the initial walk through of the resident rooms on 04/06/26 at 1:00 PM, the surveyor observed air conditioner/heater filters were dirty with a one-quarter inch dust on them in room [ROOM NUMBER], #204, and #206. The surveyor went to the nursing station closest to the resident rooms and asked Licensed Practical Nurse (LPN) #36 to accompany her to the resident rooms for observation of air filters. LPN #36 verified the filters were covered with a dust layer at 1:30 PM on 04/06/26.
- Potential for harm · Dcited before2026-04-09 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and staff interview, the facility failed to coordinate the diagnoses on the Minimum Data Set (MDS) and the Pre-admission Screening and Record Review (PASARR). This was found to be true for two (2) of four (4) residents reviewed during the long term care survey process. Resident identifiers: #7, and #19. Facility census: 59.Findings included: a) Resident #7Resident #7 was admitted to the facility on [DATE]. Upon admission, the resident had a diagnosis of major depressive disorder, vascular dementia, both dated 08/04/25 For these illnesses, the resident was prescribed -Zoloft Oral Tablet 50 MG (Sertraline HCl)The resident's PASARR was most recently completed on 01/29/24 by the facility.Question 40 of the PASARR asked about the resident's major mental illness or suspected mental illness. The facility responded None/NA to this question. b) Resident #19 This resident was initially admitted to the facility on [DATE]. Upon admission to the facility, the resident had diagnoses which included:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, observation and staff interview the facility failed to have an accident free environment for Resident #39 in regards to fall interventions. This was true for one of five residents. Resident identifier: #39. Facility Census: 59.Findings included: a) Resident #39 Medical record review revealed Resident #39 had a care plan developed for falls. The care plan called non-skid socks and non-skid strips to left strips to the left side of the bed. Observations revealed fall interventions for Resident #39 were not in place as stated in care plan, non-skid socks when in bed were not in place, non-skid strips to the left side of bed were not in place. This was verified by Licensed Practical Nurse (LPN) #38 at 10:27 AM on 04/07/26.
- Potential for harm · D2026-04-09 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and staff interview the facility failed to ensure Resident #14 was free from unnecessary medications. This was true for one (1) of five (5) residents who were reviewed for unnecessary medications. Resident identifier: #14. Facility Census: 59. a) Resident #14 On 04/09/26 at 9:42 AM a medical record review for Resident #14 found a current Physician order for Pantoprazole 40 milligrams two (2) times a day. Continued record review revealed a pharmacist recommendation made on 07/18/25. The pharmacist had noted that the resident had received a proton pump inhibitor, Pantoprazole 40 MG, two times a day and recommended to change to once daily before food. A review of this recommendation revealed the response from the physician who prescribed the medication was blank. It had no signature. A Medication Administration Record (MAR) Reviewed found Resident #14 received Pantoprazole scheduled two times a day without a change in the 07/18/25 order, through 04/07/26. On 04/09/26 at 9:30 AM during an Interview with the Director of Nursing (DON) she stated the Pantoprazole…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to submit a Five-Day Follow-Up Investigation report to the required agencies following an Initial Reporting of Allegations. This failed practice had the potential to affect a limited number of residents. Facility census: 54. Findings included: a) On 05/13/25, a Facility Reported Incident (FRI) dated 09/24/24 was reviewed. Fax confirmation sheets were not found for the Five-Day Follow-Up Investigation. On 05/13/25 at 12:24 PM, the Administrator confirmed they did not have the fax confirmation sheets. The Administrator asked the state surveyor to contact the Office of Health Facility Licensure and Certification (OHFLAC) to obtain the Five-Day Follow-Up. The state surveyor replied OHFLAC did not have the follow-up investigation on file. The Administrator stated, I'll go look for it. The Administrator stated she was going to contact the fax company to see if they can trace the job number. No additional information was provided.
- Potential for harm · E2024-10-03 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide information, and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner. This failed practice affected more than a limited number of residents who currently resided in the facility. Resident identifiers: #3, #6, #7, #29, #33, #36, #37, #45, and #46. Facility census: 60 Findings included: a) RSV immunization During an interview, on 10/02/24 at approximately 11:18 AM, the Infection Preventionist (IP) #36 stated the facility had contended with an outbreak of RSV in January 2024. During a follow up interview with IP #36 on 10/03/24 at approximately 10:55 AM, she confirmed that to her knowledge, the residents had not been provided with educational information about the risks and benefits of receiving the Respiratory Syncytial Virus (RSV) vaccination. She further confirmed that the facility had not offered the RSV vaccine during the Fall immunization period of 2023. Record review for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interviews, the facility failed to have clean sanitized, steam table, freezer, refrigerators and dish room. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census. 60. Findings included: a) Kitchen tour Initial tour on 09/30/24 at 11:30 AM found: 1. Floor in walk in freezer had debris and dirt 2. Floors in the walk-in refrigerator had debris and dirt 3. The reach in refrigerator had debris and food spillage in the inside and spillage on the outside. 4. The Floor in the dish room had multiple missing floor tiles with brown and black substances in area making it an issue to have a clean floor and area around the dish machine. 5. A black substance on the walls around the dish machine. During an interview with the Dietary Manager during the initial tour all the issues above were verified. The Dietary Manager said the issues would be fixed. She stated the corporate representative provided her with a cleaning schedule form that had not been implemented at this time. DM also stated the dish room floor had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0575 — isolatedPost a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and observation the facility failed to post, in a form and manner accessible and understandable to residents a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, and the Medicaid Fraud Control Unit. This deficient practice had the potential to affect a limited number of residents in the facility. Resident #16. Resident census: 60. Findings included: a) Required Postings Observation on 10/02/24 at 9:00 AM found the required postings were placed high on the wall. During an interview with Resident #16, on 10/02/24 at 10:45 AM, the resident was asked to read the required postings from her wheelchair. Resident #16 responded by saying, That's way too high!!! I can't see that from here. During an interview, on 10/02/24 at approximately 11:00 AM, the Administrator acknowledged that the required posting was too high for residents in a wheelchair to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: 22. Facility census: 60. Findings included: a) Resident #22 On 10/01/24 at 2:08 PM, a review was completed regarding the beneficiary protection notification liability notice(s) given for Resident #22 who was discharged to home following her last covered day of Medicare Part A services. Resident #22's last covered day of Part A Services was on 04/05/24. The facility failed to produce evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure the bathroom door and a wall in a resident room were in good repair. Room identifier: 205. Facility Census: 60. Findings included: a) room [ROOM NUMBER] On 09/30/24 at 3:40 PM, it was observed that the lower section of the bathroom door in room [ROOM NUMBER] had many multiple scrapes and scratches on it. In addition, the wall to the right of the sink in room [ROOM NUMBER] had what appeared to have been four (4) nail holes that had been plastered over leaving uneven, rough splotches on the wall in the shape of a bow tie approximately two (2) feet wide. During an interview, on 10/01/24 at 3:40 PM, the Director of Maintenance acknowledged the patched wall was visible from the hallway and did not honor the residents' right to a homelike environment. When asked, the Director of maintenance reported the wall had been patched approximately four…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2024-10-03 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to the long-term care Ombudsman for one (1) of two (2) residents reviewed for hospitalizations during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: 57. Facility census: 60. Findings included: a) Resident #57 A medical record review was completed on 10/01/24 at 12:43 PM. The record review revealed Resident #57 was transferred to the hospital on [DATE]. The record reflected the resident/resident's representative was provided with a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights. There was nothing in the electronic medical record to indicate the long-term care Ombudsman had been notified. During an interview on 10/01/24 at 2:55 PM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to coordinate with the appropriate, State-designated authority, to ensure individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs. This was true for one (1) of three (3) residents reviewed during the survey process. Resident identifier: #12. Facility Census: 60. Findings included: a) Resident #12 Record review on 10/01/24 at approximately 2:30 PM revealed that the resident was admitted to the facility on [DATE] with no diagnosis of a Level II mental illness. Record review indicated Resident #12 was diagnosed with Major Depressive Disorder on 7/31/24, and the PASARR was not revised to reflect this diagnosis. During an interview with the Admissions Director (AD) #14, and the Executive Director (ED) #79 on 10/01/24 at approximately 3:30 PM, they reviewed Resident #12's records and confirmed that the PASARR had not been revised to reflect the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide proper care and treatment, including assistive devices, to prevent a decline, maintain, or improve the resident's communication abilities, or other functional communication system. This was a random opportunity for discovery. Resident Identifier: #44. Facility Census: 60. Findings included: a) Resident #44 During the initial brief screening process on 09/30/24 at approximately 1:16 PM, Resident #44 gestured that he was unable to converse with this surveyor because he did not have his hearing aid. Upon being asked where his hearing aid was, the resident managed to imply that his hearing aid was broken. Resident motioned that he was unsure when he had lost the use of his hearing aid. Further investigation, and an interview with Licensed Practical Nurse (LPN) #24 on 10/01/24 at approximately 3:08 PM, revealed that resident's broken hearing aid had been turned into the nursing staff on 09/03/24. LPN #24 then produced a blue sticky tab dated 09/02 with a hearing aid taped to it. A review of Facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the resident received the proper treatment and assistive devices to maintain his hearing abilities. This was a random opportunity for discovery. Resident identifier: #44. Facility Census: 60. Findings include: a) Resident #44 During the initial brief screening process on 09/30/24 at approximately 1:16 PM, Resident #44 gestured that he was unable to converse with this surveyor because he did not have his hearing aid. Upon being asked where his hearing aid was, the resident managed to imply that his hearing aid was broken. The resident motioned that he was unsure when he had lost the use of his hearing aid. An interview with Licensed Practical Nurse (LPN) #24 on 10/01/24 at approximately 3:08 PM, revealed that the resident's broken hearing aid had been turned into the nursing staff on 09/03/24. LPN #24 then produced a blue sticky tab dated 09/02/24 with a hearing aid taped to it. A review of Facility's grievance policy on 10/01/24 revealed the following statement: Grievances will be resolved in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to deliver respiratory care services consistent with professional standards of practice. The physician's order for oxygen was not followed. This practice affected one (1) of three (3) residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident identifier: #2. Facility Census: 60. Finding included: a) Resident #2 A review of American Association for Respiratory Care Clinical Practice Guideline -Oxygen Therapy in the Home or Alternate Site Health Care Facility -2007 Revision & Update P1063-1067- Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. An observation of Resident #2, on 10/01/24 at 9:41 AM, revealed the resident was receiving oxygen at four and a half (4.5) Liters Per Minute (LPM) via nasal cannula (an oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and staff interview the facility failed to ensure Resident #9 who required dialysis received such services, consistent with professional standards of practice, by documenting/taking a Blood Pressure (BP) on residents left arm. This was found true for 1 of 1 resident reviewed for dialysis during the long-term care survey process. Facility census: 60. Resident identifier: 9. Findings included: a) Resident #9 1) A record review on 10/03/24 at approximately 8:40 AM found physicians' orders: -- Observe permcath to right upper chest every shift for s/s of infection and or bleeding every day and night shift. Order date active 5/7/2024. --No blood draws or blood pressure to left arm every day and night shift. Order date active 5/7/2024. --Check fistula to left arm for +thrill and +bruit every shift every day and night shift. Order date active 05/07/24. A review of Resident #9s care plan revealed an intervention: - AV Fistula in the left arm. stating not to take BP in left arm. A review of the Treatment Administration Record (TAR) found documentation from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to prepare meal trays in a safe and sanitary manner. Staff wore jewelry on the tray line. This practice has the potential to affect more than a limited number of residents. Facility census 59. Findings included: a) On 11/14/23 at 12:00 PM observations in the kitchen noted the Dietician with no gloves, a stone ring on each hand and a [NAME] bracelet on the left wrist, repeatedly taking temperatures of food without donning gloves. On 11/14/23 at 1:37 PM, Culinary Director (CD) #23 reported staff are permitted to wear a plain wedding band during meal tray service but nothing else. The above observation was reviewed with the CD #23, he agreed the dietician was stirring and checking food temperatures with her jewelry on and no gloves. At 1:45 PM on 11/14/23, the Registered Dietician (RD) #124 approached the survey team and was found to be wearing a white silicone wedding band and no other jewelry. RD #124 acknowledged she was wearing a bracelet and two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to maintain pharmacy related information, pertaining to the monthly medication regimen review, for each resident, that was readily accessible. This deficient practice was found true for five (5) of five (5) residents reviewed for the care area of unnecessary medications and for one (1) of one (1) residents reviewed for the care area of anticoagulants. Resident identifiers: Residents #28, #52, #17, # 33, #10, and #31. Census: 59. Findings included: a) Resident #28 A record review on 11/14/23, for Resident #28, showed no evidence of a monthly medication review, by the pharmacist, for the months of 08/23, 09/23 and 10/23. An interview, with the Director of Nursing (DON), on 11/14/23 at 10:45 AM, revealed there was no information noted in the medical record or in any facility documentation, showing a medication regimen review for the dates of 08/23, 09/23 and 10/23. An interview, with Registered Nurse (RN) #122, on 11/14/23 at 11:59 AM, revealed the pharmacist was contacted and was requested to send the results of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, medical record review, and staff interviews, the facility failed to ensure the Pharmaceutical services of provision, monitoring and/or the use of medication-related devices were completed on a consistent basis. This deficient practice was found during a random opportunity for discovery. Facility census: 59. Findings included: a) Emergency Kit Pharmaceutical Services refers to: The provision, monitoring and/or the use of medication-related devices per the definition by the Centers for Medicare and Medicaid Services (CMS). On 11/14/23 at 12:45 PM during an inspection of the medication room, the locked emergency kit had a note that an item in the box expired on 09/01/23. Licensed Practical Nurse (LPN) #48 acknowledged that the note indicated something had expired. LPN #48 took the box to the Director of Nursing (DON) and the Corporate Nurse. The box tie was then cut off and contents observed. Four (4) 1 cc (centimeters) syringes were identified to have expired on 06/30/23. LPN #48 removed the syringes at that time. The DON and Corporate Nurse acknowledged that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and staff interview, the facility failed to ensure a psychotropic mediation had the appropriate diagnoses. This deficient practice was found for one (1) of five (5) residents reviewed for the use of unnecessary psychotropic medications. Resident identifier: 10. Facility census: 59. Findings included: a) Resident #10 A medical record review on 11/14/23 revealed the annual Minimum Data Set (MDS) assessment with an Annual Reference Date of 10/25/23 under Section I Active Diagnoses: listed anxiety disorder, depression and insomnia as current diagnoses. The comprehensive care plan was developed for the use of Trazodone for the diagnoses of anxiety disorder, depression, and insomnia. The physician's order was for Trazodone to be given daily for insomnia only. In a interview with the Registered Nurse (RN) consultant on 11/15/23 at 10:10 AM, verified the physician's order was incomplete and should include the diagnoses of anxiety disorder and depression. .
- Potential for harm · D2023-11-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linen. This was a random opportunity for discovery. Resident Identifier: #54. Facility Census: 59. Findings Included: a) Resident #54 On 11/13/23 at 11:21 AM, soiled linens were observed laying on the floor next to bed 114-B. On 11/13/23 at 11:23 AM, Licensed Practical Nurse (LPN) #31 confirmed the soiled linens were laying on the floor. LPN # 31 stated, let me get those right now. On 11/15/23 at approximately 11:30 AM, Corporate Nurse #122 was notified and confirmed soiled linens should not be in floor. No further information was obtained during the survey process. .
- Potential for harm · D2023-09-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to develop and/or implement the care plan regarding showers for Resident #2 and #29. This was true for two (2) of four (4) residents reviewed during the survey process. Resident identifiers: #2 and #29. Facility Census: 58. Findings included: a) Resident #2 On 09/05/23 at 1:00 PM, a record review was completed for Resident #2. The care plan was reviewed as well. Under the focus area of ADL (activities of daily living) self-care deficit r/t (related to) weakness, Parkinson's and Dementia, an intervention stating Bathing: assist of one. Shower three times a week and as needed or requested. (Typed as written.) The week of 08/13/23, the resident received one (1) shower, the week of 08/20/23, the resident received one (1) shower, and the week of 08/27/23 the resident did not receive any showers. This information was found documented under the tasks tab of the electronic medical record. Upon review of residents listed as dependent for bathing, Resident #2 was listed. On 09/05/23 at 3:00 PM, the Administrator was notified and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to provide activities of daily living (ADL) care for a dependent resident. This is true for one (1) of four (4) residents reviewed during the survey process. Resident identifier: #2. Facility Census: 58. Findings included: a) Resident #2 On 09/05/23 at 1:00 PM, a record review was completed for Resident #2. The care plan was reviewed as well. Under the focus area of ADL (activities of daily living) self care deficit r/t (related to) weakness, Parkinson's and Dementia, an intervention stating Bathing: assist of one. Shower three (3) times a week and as needed or requested. (Typed as written.) The week of 08/13/23, the resident received one (1) shower, the week of 08/20/23, the resident received one(1) shower, and the week of 08/27/23, the resident did not receive any showers. This information was found documented under the tasks tab of the electronic medical record. Upon review of residents listed as dependent for bathing, Resident #2 was listed. On 09/05/23 at 3:00 PM, the Administrator was notified and confirmed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,021 in federal fines across 1 penalty.
- $8,021 — penalty dated 2024-07-03
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COMMUNICARE HEALTH — 110 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| WV LT CARE OP CO., LLC | Organization | DIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| C R STOLTZ II LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| C.R. STOLTZ IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| HC REAL ESTATE HOLDINGS, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| I. ROSEDALE IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| OMG RE HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| R.S. WILHEIM IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| RONALD S WILHEIM 2012 SPOUSAL TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| ROSEDALE FAMILY INVESTMENT COMPANY, INC | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| RRW, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| S.L. ROSEDALE IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| WILHEIM FAMILY INVESTMENT COMPANY, INC. | Organization | INDIRECT OWNERSHIP INTEREST | since 07/01/2022 |
| ROMEO, DOMINIC | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| CRESTVIEW TERRACE MGT CO., LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/16/2025 |
| CALEMINE-DOLAN, TRICIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2022 |
| GROVES, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/14/2023 |
| MALONE, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2022 |
| STOLTZ, CHARLES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2022 |
| WILHEIM, RONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2022 |
| ODENTHAL, RICHARD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 12/01/2025 |
CMS files one row per role, so the 24 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WV
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the West Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 515141. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.