Holbrook Healthcare Center

Location & what’s nearby

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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

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.

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.

Met the expected recovery: 45.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 106.5 residents a day — about 89% occupied, or roughly 14 beds typically open. It runs fairly full. 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 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.96 hrs/resident/day on weekends vs 3.52 on weekdays — 16% thinner on weekends. RN hours go from 0.30 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 more than at the previous inspection — worsening. 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.

42 citations, most serious first. The 14 most serious are shown; the remaining 28 are one tap away and print in full.

• Immediate jeopardy · K2025-07-29 · tag F0807 — failed to offer suitable drinks — pattern
  Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
  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, staff interview and resident review, the facility failed to provide liquids in the correct consistency to meet the resident's individual needs. This was true for three (3) of seven (7) residents that were ordered nectar and honey thickened liquids. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #7, #82, and #31. Facility Census: 107.Findings included: a) On 07/21/2024, Residents #7, #82, and #31 were observed to liquids at bedside that were not nectar or honey consistency during the investigation process. This failed practice created an immediate jeopardy situation.During the initial resident interview process, Resident #7 received thin liquids with the lunch meal in a spouted cup. The resident also had a mug with a straw on the tray table containing ice water. On 07/21/2025 at 01:10 PM, NA #12 confirmed both cups contained thin liquids. Nursing Assistant (NA) #12 stated, I think she's allowed to have some thin liquids.…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-12-28 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 staff interview and record review, the facility failed to implement their written Abuse and Neglect policy as it related to reporting allegations of abuse and failed to follow procedures to investigate any such allegations. Their lack of action to investigate the abuse allegation placed Resident #1 at continued risk of staff abuse for six (6) days prior to Surveyor intervention. Review of facility records found that there were 30 other residents who had a BIMS (Brief Interview for Mental Status) score between 0-7, suggesting severe cognitive impairment. They also were at risk of staff abuse. Resident identifiers: #1, #3, #6, #10, #13, #14, #17, #26, #34, #36, #37, #38, #44, #49, #50, #53, #55, #57, #60, #66, #67, #68, #75, #87, #89, #95, #97, #99, #103, #104, #111. Facility Census: 107. Findings included: a) West Virginia Abuse, Neglect and Misappropriation Policy Review of the facility's West Virginia Abuse, Neglect and Misappropriation Policy revealed the following details: - Abuse was defined as…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-12-28 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 complete a thorough investigation of a staff member's allegation of resident abuse, maintain documentation that alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. The facility's failure to complete a thorough investigation of a staff member's allegation of resident abuse left residents who were deemed to be severely cognitively impaired at risk of further abuse. In addition, the facility failed to ensure the victim was protected from further abuse which put the residents at risk for additional serious harm and or death. Findings included: a) Staff Interview with CNA #22 During a telephone interview on 12/26/23 at 6:30 PM, CNA #22 stated other CNAs working the evening shift will purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors then staff giggle about it. They will get in his face and shake his chair, pull his hat off his…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-12-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on policy review, record review, and staff interview, the facility failed to protect a resident's right to be free from abuse that resulted in mental anguish for Resident #1. This was a random opportunity for a discovery made during a complaint investigation. Resident identifier: #1. Facility census: 107. Using the reasonable person concept, the facility's failure to protect a resident's right to be free from abuse resulted in mental anguish for Resident #1 and had the potential to cause serious harm and or death. This was true for Resident #1. Facility Census: 107. Findings included: a) West Virginia Abuse, Neglect and Misappropriation Policy Review of the facility's West Virginia Abuse, Neglect and Misappropriation Policy revealed the following details: - Abuse was defined as intimidation or punishment resulting in physical harm, pain, or mental anguish. It was noted that abuse included mental abuse. - Physical Abuse was noted to include, but not be limited to, hitting slapping, pinching, biting, and kicking. - Verbal Abuse was noted to include the use of gestured…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-07-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor 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

  Based on observation, resident interview and staff interview, the facility failed to provide a homelike dining experience for residents served in the main dining room and to ensure resident areas were clean and odor free. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifiers: #90 and #5. Facility Census: 107. Findings included: a) On 07/21/2025 at 12:30 PM, during the Dining Room Observation, no tablecloths were on the tables in the main dining room and the residents were served their meals on plastic trays from the kitchen. On 07/21/2025 at 12:33 PM, Licensed Practical Nurse (LPN) confirmed the residents were eating their lunch on trays and stated, When there's tablecloths .we usually take them off. b) Resident #90 On 07/22/2025 at 10:50 AM, during the initial resident interview, Resident #90 reported they don't clean her bed pan box. The resident stated the smell comes out of her bathroom into her room at times. In the resident's bathroom, a white plastic standing box was observed containing 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-07-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure 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, record review and staff interview, the facility failed to ensure food was stored in accordance with professional standards for food services. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 107. Findings included: During the Kitchen Investigation initiated on 07/21/2025 at 11:45 PM., the following items were found: a) Sausage patties - bag was not sealed and no use by date. b) Four (4) bags of hoagie buns bags - not labeled and no use by date. c) Crinkle cut fries were in a bag - not labeled. d) Baked beans in a plastic container - no used by date. On 07/21/2025 at 11:50 AM, Regional Dietary Manager #128 confirmed the items and stated, I didn't know you had to label if you know what it is. On 07/22/25 at 11:05 PM, the following items were found in the Nutrition Station 100-200: a) Two (2) bologna and cheese sandwiches - not labeled and no use by date. b) [NAME] cheeseburger - not sealed and no use by date. Items were confirmed by…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-07-29 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard 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, staff interview and record review the facility failed to ensure it had a complete and accurate medical record. This failed practice was found true for (6) six of 36 residents reviewed for medical record accuracy during the Long- Term Care Survey Process. Resident identifiers #43, #6, #7, #10, #4, and #77. Facility Census 107. Findings include: a) Resident #43 A record review on 07/23/25 at 10:31 AM, revealed a capacity form dated and signed by Family Nurse Practitioner (FNP) on 03/28/25 for Resident #43 stating that the resident has capacity. Further record review revealed a Physicians Orders for Scope of Treatment (POST) form for Resident #43 dated 03/28/25 and signed by Resident #43's Medical Power of attorney (MPOA), rather than being signed by Resident #43, who had capacity. Post form for Resident #43, was signed by the MPOA, rather than Resident #43 that has capacity. During an interview on 07/23/2025 at 10:43 AM, The Administrator confirmed that the POST form was signed by the MPOA and not by Resident #43 who has capacity. A review on 07/23/2025 at…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-29 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based upon record review and staff interview, the facility failed to inform the Resident or the Resident's representative of the risks and benefits for a prescribed psychotropic medication. This was found to be true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #77. Facility census: 107.Findings included: a) Resident #77 A review of the electronic health record (EHR) revealed the following diagnoses for Resident #77:Unspecified Dementia - 12/21/24 Generalized Anxiety Disorder - 03/20/25Alzheimer's - 03/20/25 Upon reviewing progress notes from the facility's medical provider dated 03/16/25, an additional diagnosis of major depressive disorder was revealed. Additionally, a progress note dated 06/10/25 by the provider, stated a diagnosis of Major depressive disorder, recurrent, moderate. The electronic health record does not contain the diagnosis for major depressive disorder under the list of diagnoses. The medical provider orders for the Resident included the following anti-depressants:Sertraline HCl Tablet 25 MG Give 1 tablet by…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-29 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  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, staff interview, and family interview the facility failed to inform the Medical power of Attorney (MPOA) of appointments for Resident #55, and failed to notify the physician and responsible party of a change in condition for Resident #7. This failed practice was found true for (2) two of (2) two residents reviewed for notification of change during the Long-Term Care Survey Process. Resident identifiers #55, and #7. Facility Census 107. Findings include: a) Resident #55 During a phone interview on 07/22/25 at 11:40 AM, The MPOA, for Resident #55 stated, A couple months ago they took him (Resident #55) all the way to Morgantown for a Dermatology appointment to have a procedure done. I only found out about the appointment because the doctor’s office called me to get permission to treat him. That's about 45 minutes away. A review of the Grievance Log on 07/24/2025 at 1:03 PM, revealed that the MPOA for Resident #55 filed a grievance about not being notified of the dermatology appointment on…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-29 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 the required notifications to a resident transfered to the hospital. This deficient practice affected one (1) of three (3) residents reviewed for the care area of hospitalization. Resident Identifier: #104. Facility Census: 107.Findings included: a) Resident #104 Review of Resident #104's medical records showed the resident was emergently transferred to the hospital on [DATE]. The resident reported emesis and shaking, stating she felt like she did when she previously had a myocardial infarction. The resident had capacity to make her own medical decisions. Further review of Resident #104's medical records did not reveal the following discharge documentation: - Written notification to the resident of the reasons for the transfer.- Notice of the facility's bed-hold policy and duration. On 07/24/2025 at 10:43 AM, Regional Clinical Coordinator #131 confirmed there was no evidence the written transfer/discharge notification and the bed hold…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-29 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based upon record review and staff interview, the facility failed to maintain accuracy of the Minimum Data Set (MDS) Resident Assessment and Care Screening for a diagnosis of major depressive disorder. This was found to be true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #77. Facility census: 107. Findings included:Resident #77's list of diagnoses, related to mental illness, included the following:Unspecified Dementia, Mild with AnxietyGeneralized Anxiety DisorderAlzheimer's DiseaseDuring a review of the medical record for the Resident, the progress notes dated 03/16/25 and 06/10/25 by Resident's medical provider, recorded the following diagnoses:Generalized anxiety disorderUnspecified dementia, mild, with anxietyMajor depressive disorder, recurrent, moderateThe Minimum Data Set (MDS) Resident Assessment was last completed on 06/17/25. Under Section I - Active Diagnoses included:Alzheimer's DiseaseNon-Alzheimer's DementiaAnxiety DisorderUnspecified Dementia, Mild, with AnxietyIn summary, the diagnosis of Major Depressive Disorder…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-29 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop 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 upon record review, resident interview and staff interview, the facility failed to develop a personalized care plan for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). This was found to be true for one (1) of thirty-six (36) residents reviewed during the annual survey process. Resident identifier: #4. Facility census: 107.Findings included: During an interview with Resident #4 on 07/21/25 at 12:01 PM, the resident appeared to be very withdrawn, his face void of emotion. He was sitting alone, in his wheelchair, outside of his bedroom door. After conversing with the resident for several minutes, he stated he had served two deployments with the Army in IRAQ. We talked about his care, the food, his ability to make choices, etc., and he stated everything was ok. The resident finally smiled once before we ended our conversation. A review of the resident's electronic health record (EHR), revealed he has the following diagnoses:Post-Traumatic Stress Disorder Chronic (PTSD) 04/18/25 AdmissionDepression, Unspecified 04/18/25 AdmissionHis Care Plan, dated 04/17/25,…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide 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 family interview, staff interview, record review, and observation the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (8) eight residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier: #55. Facility Census: 107. Findings include: a) Resident #55 During a phone interview on 07/22/25 at 11:40 AM, The Medical Power of Attorney (MPOA) for Resident #55 stated, Every time I come to visit his fingernails need cut. Sometimes it makes indentions in his hand. An observation on 07/23/25 at 1:43 PM, of Resident #55's right and left hand, showed that he had fingernails that were long and jagged on both hands. A record review on 07/23/2025 at 1:46 PM, revealed an ADL care plan for Resident #55 that reads as follows:Focus: (Resident #55 named) has ADL Self Care Performance deficit with further decline expected related to progressive vascular leukoencephalopathy, MS, neoplasm of parotid gland requires assistance with ADL related to hx of CVA with L side…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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, observation, and staff interview, the facility failed to ensure residents did not develop preventable pressure ulcers. The facility also failed to ensure residents with pressure ulcers received assessment in accordance with professional standards of practice. This deficient practice had the potential to affect two (2) of four (4) residents reviewed for the care area of pressure ulcers. Resident Identifiers: #110. Facility census: 107. Findings included:a) Resident #110 The facility's policy and standard procedure titled, Monitoring a Wound, with no date of implementation given, stated resident skin condition would be evaluated upon return from the hospital. Review of Resident #110's medical records showed the resident had an unstagable pressure ulcer of the right gluteal fold first assessed on 03/08/25 when the resident returned from a hospital transfer. The right gluteal fold pressure ulcer became a stage IV pressure ulcer and was present through 07/07/25, when the resident was…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$79,108 in federal fines across 2 penalties.

• $18,941 — penalty dated 2025-07-29
• $60,167 — penalty dated 2023-12-28

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 →

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

CMS files one row per role, so the 23 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

12 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 86% 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 $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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