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Cameron Healthcare Center

20 Wilson Drive, Cameron, WV 26033 · For profit - Corporation · 60 certified beds · (304) 686-3318 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Aug 2024Resident-funds citation (F0565)1 immediate-jeopardy citation$131,164 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2024
  • 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
  • it has a citation for mishandling residents’ money or property (F0565)
  • 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 $131,164 in federal fines (most recent 2024-08-16)
  • 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.

4/5
CMS overall
4 of 5
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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Wilson Dr · (304) 686-3376 · Call to confirm hours
Pharmacy
1 Bridge St · (304) 686-2101 · Call to confirm hours
Grocery
The Store9.6 mi
5108 Roberts Ridge Rd · (304) 845-0502 · Call to confirm hours
Park
12th St · (304) 845-7733 · Typically dawn to dusk
Place of worship

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 3 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.0%14.7%15.4%better
Long-stay residents who lose too much weight4.0%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.6%2.0%better
Long-stay residents with depressive symptoms1.7%7.6%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.4%4.4%3.3%worse
Long-stay residents whose ability to walk worsened11.3%15.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.0%27.0%18.9%worse
Long-stay residents given the seasonal flu vaccine92.7%97.6%95.3%typical
Long-stay residents with pressure ulcers2.2%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control24.9%22.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.3%13.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.0%1.4%better
Short-stay residents given the seasonal flu vaccine72.0%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.

0.26U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS 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

0.42
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.24
RN hoursweekends
33.3%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 53.9 residents a day — about 90% occupied, or roughly 6 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.01 hrs/resident/day on weekends vs 3.54 on weekdays — 15% thinner on weekends. RN hours go from 0.49 to 0.24 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%.

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

6
deficiencies at the latest standard inspection (2026-03-04)
10
at the previous standard inspection (2024-08-16)

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.

ABCDEFGHIJKL

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 · J2024-08-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interview, the facility failed to protect residents from resident abuse. The facility failed to provide a safe environment for Residents. The deficient practice put five (5) of five (5) Residents at risk for serious injury, serious harm, serious impairment, or death. Resident Identifiers #32, #52, #14, #49, #36, and #24. Facility census: 52. The facility was notified of the Immediate Jeopardy (IJ) at 6:53 PM on 08/13/24. The facility submitted their first abatement plan of correction (POC) at 7:28 PM on 08/13/24. The POC was accepted by the state agency at 7:47 PM on 08/13/22. After observation of the implementation of the abatement POC, the IJ was abated at 3:30 PM on 08/14/24. The IJ started on 08/13/24 and ended on 08/14/24. The facility's approved abatement POC consisted of the following: Correction action for area of concern- - Education to all staff in building at current time with remaining education to all staff 8/14 - education will be on 1:1…

    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 before2026-03-04 · 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, staff interview and policy review the facility failed to provide a comfortable home like environment in the communal shower room. This failed practice was a random opportunity for discovery and had the potential to effect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier: #42. Facility census: 54.Findings Include:a) Communal Shower RoomDuring the initial interview on 03/02/26 at 12:40 PM, Resident #42 stated, The shower room is cold. That is why I wash myself off at the sink a lot of days.An observation on 03/02/26 at 1:00 PM, revealed the shower room felt cool. There was no thermometer in the shower room to get the actual temperature.A further observation of the communal shower room at 1:05 PM, with The Director of Maintenance (DOM), confirmed the room felt cool and noted there was no thermometer to get the actual temperature. The DOM took the room temperature with the water temperature thermometer, which read 71 degrees Fahrenheit. The State Agency (SA) asked if he had a wall thermometer…

    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 before2026-03-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of clinical records, facility documentation, and staff interviews the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases, to help prevent cross-contamination and infections including Covid-19 in regard to, follow CDC (Centers for Disease Control) guidelines for use of PPE (Personal Protective Equipment) and ensure staff donned appropriate personal protective equipment (PPE) prior to wound care for a resident on (Enhanced Barrier Precautions) and provide appropriate wound cere. The facility also failed to ensure the laundry area had bags of trash and dirty laundry in receptacles. These failed practices had the potential to affect every resident currently residing in the facility. Resident identifier:# 2. Facility census: 54. Findings included: a) Resident #2A record review revealed Resident #8 was in Enhanced Barrier Precautions (EBP) due to wound care.On 03/02/26 at 2:00 PM, Licensed Practical Nurse (LPN) #35 with assistance from Nurse Aide (NA) #56 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · 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 on staff interview and record review the facility failed to ensure medical assessments regarding the frequency of falls were completed accurately.This deficiency was identified in one (1) out of two (2) records reviewed. Resident identifier: #6. Facility census: 54. Findings include:a) Resident #6Review of Resident Assessment Instrument (RAI) manual for Minimum Data Sheets (MDS) Section J1800 reads in part, Any falls since admission/entry or reentry or prior assessment, whichever is more recent. Section: J1800 of the MDS, with an Assessment Reference Date (ARD) of 08/18/2025 revealed the MDS registered nurse ( RN) marked the answer as (no) to the question Any falls since admission/entry or reentry or prior assessment, whichever is more recent. Record review revealed Resident #6 had fallen on 05/12/25, 06/07/25, 06/08/25. During an interview on 03/03/26 at around 11:30 AM with MDS RN #27, the RN reviewed observations and reported, I may have missed these, as they should have been answered yes. It could be an error on my end. I will go back and review and return to verify 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · 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 resident interview and record review the facility failed to provide Activities of Daily Living (ADL) care to dependent residents during meal times. This failed practice was found true for (1) one of (3) three residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier: #11. Facility census: 54.Findings Include:a) Resident #11During the initial interview on 03/02/26 at 12:35 PM, Resident #11 stated, About a week ago, I asked to have my brief changed about 15 minutes before supper and was told by the nurse aide that I would have to wait until after the meal.A record review on 03/04/26 at 9:30 AM, revealed an ADL care plan for Resident #11 that had an intervention that read as follows:Toileting Hygiene: Totally dependent of 1, 1 helper does all the effort. Resident does none of the effort.During the Resident Council meeting with the State Agency (SA) on 03/03/26 at 10:15 AM, The Resident Council as a whole said they are being told they have to wait until after meals to be changed or taken to the restroom.During an interview on 03/04/26 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on record review and staff interviews, the facility failed to provide care and services in-accordance with professional standard of practice in regards to adverse drug consequence, Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The resident had not yet experienced side effects from the medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #9. Facility census: 54.Findings included:a) Resident #9Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The resident had not yet experienced side effects from the medication. A review for Unnecessary Medication regarding Resident #9 identified that Acetaminophen was added to the drug allergy list on the admission date of…

    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 · D2026-03-04 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews Medication Regimen review (MRR) failed to evaluate and report on the potential adverse consequences for a resident to receive a medication in which they had a listed drug allergy. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #9. Facility census: 55.Findings included:a) Resident #9A review for Unnecessary Medication regarding Resident #9 identified that Acetaminophen was added to the drug allergy list on the admission date of 12/24/25.Continued medical record review revealed an order: Acetaminophen Oral Tablet 325 MG (Acetaminophen): Give 650 mg by mouth every four hours as needed for Pain. Order date: 02/02/26.A review of Resident #9's medication administration record found Acetaminophen 650 mg was given on 02/20/26, 02/21/26 and 03/04/26.Subsequent review of Resident #9's Medication Regimen Review (MRR) for February 2026 revealed that Acetaminophen was not noted as an Adverse Consequence.On 03/04/26 at approximately 10:00 AM, the Director of Nursing (DON) verified that neither 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-16 · 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 observations and staff interview, facility staff failed to provide the housekeeping services necessary to maintain a safe, clean, comfortable, and homelike environment, by not maintaining the water temperature at a comfortable level for residents, and not ensuring that the shower rooms, and residents bathrooms were free of any accumulated dirt, grime, or other substances, and foul odors. Resident Identifiers: #4, #10, and #13. Facility Census:52. The findings included: a) Resident #4: During an interview with Resident #4 on 08/12/24 at 1:22 PM, she stated that the water was always cold when she was given a shower. An inspection of the resident's hand sink revealed no hot water, even after the water was left running for over three minutes. NA #8 confirmed that water temperature was cold. b) Resident #10 During an inspection of Resident #10's bathroom on 08/12/24 at 1:44 PM, a black substance was noted between the floor tiles. NA #8 responded to this surveyor's request and confirmed the black substance. She stated that the floor needed to be cleaned. c) Resident #13 An…

    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 · E2024-08-16 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and staff interviews the facility failed to ensure the facility nursing staff posting was completed for the day shift. This was a random opportunity for discovery during the revisit survey. Facility Census: 53 Findings include: On 10/02/24 at approximately 9:32 AM a surveyor observed the Nursing staffing sheet hung at the end of C - Hall was not completed for the Day shift. During an interview with Licensed Practical Nurse (LPN) #40 confirmed the staffing sheet should have been completed. The LPN stated, I'm doing it now we have been passing meds. An interview with the Director of Nursing (DON) was completed on 10/02/24 at 12:00PM. The interview confirmed the staffing sheet should have been completed at the beginning of day shift. Record review on 10/02/24 of the facility's policy #: NS 1091-01 under Procedure it stated, The facility will post the nurse staffing data daily at the beginning for each shift.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-16 · 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

    Based on observation and staff interview, the facility failed to dispose of expired food items. This failed practice had the potential to affect more than a limited number of residents who were served food from the kitchen. Facility census: 52. Findings included: a) Initial Tour of Kitchen During the initial tour of the kitchen, on 08/12/2024 at 11:30 AM, with the Dietary Manager revealed One (1) unopened box of muffin mix found to have an expiration date of 07/04/23, stamped on the container by the manufacturer. The Dietary Manager stated This should have been thrown out and immediately disposed of muffin mix. Based on observation and staff interview, the facility failed to dispose of expired food items. This failed practice had the potential to affect more than a limited number of residents who are served food from the kitchen. Facility census: 52. Findings included: A) Initial Tour of Kitchen with Dietary Manager My Observations during the initial tour of the kitchen, on 08/12/2024 at 11:30 AM, revealed: One unopened box of muffin mix found to have an expiration date of…

    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 before2024-08-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews with facility staff, and a review of facility policy and procedures, it was determined that the facility failed to follow acceptable infection control practices that controlled, or prevented, the spread of infection. This practice had the potential to affect all residents that reside in the facility. Facility Census: 52. Findings included: a) Water Management During facility record review of the water management, it was revealed that the facility did not have a Water Management Plan, or a water flow diagram which identified the facility's water systems for which Legionella control measures were needed. No documentation was maintained, or provided, describing facility's control practices to prevent growth of water borne pathogens. b) Laundry Services On 08/14/24 at 2:16 PM an inspection of the soiled laundry room, accompanied by Director of Plant Maintenance (DPM) #13 observed that the door between the soiled laundry room and clean laundry room was held open by a box of detergent. The clean laundry room contained a rack of uncovered clean clothing in…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-08-16 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and resident and staff interviews, it was determined that the facility staff failed to treat residents with respect and dignity, and to allow the residents the right to exercise his or her rights as a resident of the facility. This finding was true for one (1) of two (2) residents reviewed for the dignity care area during the survey. Resident Identifier #4. Facility Census: 52. Findings Included: a) Resident #4 During an interview on 08/12/24 at 2:57 PM, Resident #4 stated that she prefers to use a bedpan when voiding. Resident is non-ambulatory. Her diagnoses include fibromyalgia, acute and chronic respiratory failure, muscle wasting and atrophy of right and left upper arms, generalized muscle weakness, and morbid obesity. Resident is on oxygen, and requires substantial assistance, including the use of a lift for transfers. Resident stated that when Nurse Aide (NA) #53 was on duty, he refused her request for a bedpan, stating You call for a bedpan more than anyone else in the facility. Instead, NA #53 insists that resident use the bedside commode. Resident…

    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 · D2024-08-16 · tag F0575 — isolated
    Post 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 — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to have the Ombudsman information posted that was easily accessible for residents. This failed practice had the potential to affect more than a limited number of residents who are not tall enough or in wheel chairs. Facility census: 52. Findings included: a) Resident Council Meeting During a Resident Council meeting on 08/14/24 at 9:30 AM, the residents stated they were aware of their rights and knew where the Ombudsmen phone number was located. They further stated that the board was not low enough for them to read it. They went on to state that the board is too high for them to get the number without asking for assistance. On 8/14/2024 at approximately 11:35 AM, the Social Worker confirmed the Board for resident rights and Ombudsman information was too high for the residents in wheel chairs to read.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 report a fall with serious injury to the required agencies within the specified time period. This failed policy had the potential to affect an isolated number of residents that reside in the facility. Resident Identifier: #37. Facility census:52. Findings Included: a) Resident #37 Review of records on 08/13/24 at 11:32 AM revealed a note dated 7/22/2024 at 1:33 AM by Licensed Practical Nurse (LPN) #43. The note stated: Resident fell and hit head in her bathroom large knot and laceration above the left eye. (name) MPOA notified. Telehealth called and gave orders to transfer resident to local hospital. Resident complains of neck pain and some bruising to right hand and left knee. Another note on 7/22/24 at 5:11 AM by LPN #35 stated: Nurse at (local hospital) said resident is being transferred to (area trauma center). She has a laceration to forehead, contusion to (L)chest wall, contusion to face, CT showed cervical fracture. During an interview with the Social Worker on 08/14/24 at 1:58 PM she produced a Facility…

    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 · D2024-08-16 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review), during the Long-Term Care Survey process. Resident identifier: #39. Facility census: 52. Findings included: a) Resident #39 A record review, completed on 08/13/24 at 7:30 PM, revealed Resident #39 had been admitted to the facility on [DATE] with an admitting diagnosis of Major Depressive Disorder. The admitting PASARR, dated 12/09/21, did not identify Resident #39 had a major depressive disorder on Section III, Question 30 of the PAS. A continued record review also revealed there was never a new PAS completed that revealed resident's major depressive disorder diagnosis in order to address whether or not specialized services were needed. During an interview on 08/14/24 at 9:45 AM, the Social Worker acknowledged the admitting PAS failed to…

    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 · D2024-08-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 residents who experienced weight loss of five (5) pounds or more were re-weighed to verify weight was correct. This was true for one (1) of one (1) resident's reviewed under the nutrition pathway during the Long-Term Care Survey Process. Resident Identifier: #38. Facility census: 52. Findings included: a) Resident #38 A record review, completed on 08/13/24 at 2:02 PM, revealed there was a physician order for resident to have weekly weights. The review also revealed the following weights for Resident #38: -On 02/12/2024 at 1:01 PM, Resident weighed 90.0 Lbs. -On 02/21/2024 at 2:38 PM, Resident weighed 81.4 Lbs. -On 03/01/2024 at 9:10 AM, Resident weighed 81.0 Lbs. A review of the facility's Resident Height and Weight policy, completed on 08/13/24 at 2:33 PM, revealed the following guidelines for obtaining a resident's weight: --Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, Reweigh resident to verify weight. --Documentation: In EHR (Electronic Health Record) During an…

    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 · E2022-10-12 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident council minutes review, resident interviews, review of the facility's grievance log, and staff interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances. This had the potential to affect an unlimited amount of residents living in the facility. Facility census: 53. Findings included: a) Resident Council Minutes A review of resident council minutes was conducted on 10/11/11/22 at 11:00 AM. The following concerns/grievances were reported: 12/21/21 Resident Council --Residents would like to know who their aide is first thing in the morning. 01/18/22 Resident Council --It was noted under Old Business, [The Administrator's First Name] is going to address resident concern of knowing who their nurse aide is at the beginning of the shift. 03/24/22 Resident Council: --Shower room is not clean. there is a black substance on the right hand side in every stall. 04/28/22 Resident Council: --Showers continue to have mold, not cleaned enough. --Water pressure…

    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 before2022-10-12 · 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 resident interview, observation and staff interview, the facility failed to maintain a clean and safe shower room. This is true for one of one shower room utilized by all residents. Resident census: 53. Findings include: a) Resident interviews On 10/10/22 at 9:40 AM Resident (R) #28 complained the facility's only shower room was moldy and unclean. R #28 stated the shower chair and walls are moldy. The shower is not cleaned between residents and stool increments are left on the floor. Staff push the wheel chair through the stool and make no attempts to clean the wheel chair afterwards. At 10:00 AM on 10/10/22 R #13 voiced concerns related to the shower room being moldy and dirty and not cleaned between residents. On 10/10/22 at 1:14 PM, R #3 reported the shower room needed repaired and was not cleaned between residents. R #3 stated her wheel chair was wheeled though stool left on the floor and dirty bed side commodes are reused for other residents in the shower room. b) Observations On 10/10/22 at 12:00 PM an observation of the facility's only shower room with Nurse Aide…

    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 · D2022-10-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, record review, and staff interview, the facility failed to make a reasonable accommodation for a resident's room temperature preference as it related to his Chronic Obstructive Pulmonary Disease (COPD) and Anxiety diagnoses. Resident identifier #22. Facility census: 53. Findings included: a) Resident #22 During an interview, on 10/10/22 at 10:42 AM, Resident #22 stated he has breathing issues from his COPD diagnosis. Resident went on to say he would prefer to have his room at a cooler temperature than 71 degrees Fahrenheit. Any time he tries to address the fact that he finds it harder to breathe when the room is not cool, resident reports he is told the room must stay at 71 degrees Fahrenheit with no exceptions. Resident #22 stated he feels mistreated and unheard. When asked to explain his reasoning for a cooler temperature, Resident #22 listed the following concerns: --I feel like I can't catch my breath if the room gets too warm for me. It makes breathing harder. --I experience higher levels of anxiety. --I don't rest as well throughout the night. --I…

    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 · D2022-10-12 · tag F0582 — isolated
    Give 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide evidence the required Notification of Medicare Non-Coverage (NOMNC) notice 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 their rights prior to the end of Medicare Part A covered services. Resident identifier: #206. Facility census: 53. Findings included: a) Resident #206 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 instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. a) Beneficiary Notice Review On 10/11/22 at 10:55 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who was discharged home. --Resident #206 -…

    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 before2022-10-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility documentation of reportable occurrences , and staff interview, the facility failed to ensure that all alleged violations of abuse and neglect, including incidents resulting in serious bodily injury, were reported immediately, and failed to ensure the results of the investigation were reported within five (5) working days of the occurrence, to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Resident #51 sustained serious bodily injury in the facility and the injury was not reported within two (2) hours of staff's knowledge of the severity of the resident's injuries sustained from a fall. This deficient practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #51. Census: 53. Findings included: a) Resident #51 Review of Operations Policy: Freedom from Abuse, Neglect 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to revise the care plan for a resident with contractures. This is true for one of one resident reviewed for range of motion. Resident identifier: #12. Facility census: 53. Findings include: a) Resident (R) #212 Review of the medical record on 10/10/22, revealed resident #12 was admitted to the facility with contractures and muscle spasms of all extremities following an anoxic brain injury. The physician note dated 03/23/21 identifies the addition of Valium to help reduce muscle tension in the hip, leg and arm contractures. The physician order written 03/24/22 states Valium five milligrams four times a day related to contractures of the hands. The care plan notes the use of Valium for anxiety but lacks information related to it's use for R #12's contractures and muscle spasms. During an interview on 10/11/22 at 1:30 PM Registered Nurse (RN) #4 and RN #74 reviewed the medical record and confirmed the Valium was added to help R #12 with contractions and anxiety. RN #4 acknowledged the care plan was not updated to…

    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 · Dcited before2022-10-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on medical record review and staff interview, the facility failed to ensure Resident #32 received medications as ordered by the physician. NovoLOG (a medication used to control blood sugar in people with diabetes mellitus) was not administered and documented in accordance with professional standards of practice. This affected one (1) of five (5) residents reviewed for unnecessary medications during the long-term care survey process. Resident identifier: #32. Facility census: 53. Findings included: a) Resident #32 On 10/11/22 at 6:39 PM, a medical record review displayed the following physician order with a start date of 07/20/22, NovoLOG PenFill Solution Cartridge 100 UNIT/ML (Insulin Aspart). Inject 6 units subcutaneously one time a day related to Type 2 Diabetes Mellitus. The Medication Administration Record (MAR), on 09/10/22 at 12:00 PM, was left blank. During an interview on 10/12/22 at 10:04 AM, the Registered Nurse Assessment Coordinator (RNAC) confirmed the MAR was left blank for the 09/10/22 at 12:00 PM timeframe which was not within professional standards of…

    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 · D2022-10-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to maintain an accurate medical record for two (2) of 17 sampled residents reviewed during the Long-Term Care Survey process. Resident identifiers: #27 and #32. Facility census: 53. Findings included: a) Resident #27 During a brief record review, on 10/10/22 at 2:58 PM, it was determined: --Resident #57 was admitted on [DATE] with a diagnosis of paranoid schizophrenia. --Additionally, on 06/03/22, the Social Services Supervisor completed a Pre-admission Screening and Resident Review (PASARR) form which did not identify schizophrenia as a diagnosis for Resident #27. During an interview on 10/12/22 at 1:43 PM, the Social Service Supervisor stated, It was an oversight that the schizophrenia diagnosis was not listed on the PASARR and the form was not filled out correctly. b) Resident #32 A brief medical record review, completed on 10/10/22 at 2:25 PM, found the following: -- A Living Will, dated 05/31/18, signed by Resident #32 when she had capacity…

    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

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$131,164 in federal fines across 1 penalty.

  • $131,164 — penalty dated 2024-08-16

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 →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 2 of 52.6-0.6 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 109 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Allen View Healthcare CenterSpringfield, OH 1 of 5Annandale Healthcare CenterAnnandale, VA 1 of 5Canfield Healthcare CenterYoungstown, OH 1 of 5Dixon Healthcare CenterWintersville, OH 1 of 5Holbrook Healthcare CenterBuckhannon, WV 1 of 5Mount Vernon Healthcare CenterAlexandria, VA 1 of 5Southwood Healthcare CenterTerre Haute, IN 1 of 5Summers Healthcare CenterHinton, WV 1 of 5Valley View Healthcare CenterElkhart, IN 2 of 5Allison Pointe Healthcare CenterIndianapolis, IN 2 of 5Battlefield Park Healthcare CenterPetersburg, VA 2 of 5Beckley Healthcare CenterBeckley, WV 2 of 5Belmont Healthcare CenterBelmont, WV 2 of 5Berkeley Springs Healthcare CenterBerkeley Springs, WV 2 of 5Cedars Healthcare CenterCharlottesville, VA 2 of 5Columbus Healthcare CenterColumbus, OH 2 of 5Crestwood Care CenterShelby, OH 2 of 5Cumberland Healthcare CenterCumberland, MD 2 of 5Eagle Pointe Healthcare CenterParkersburg, WV 2 of 5Ellicott City Healthcare CenterEllicott City, MD 2 of 5Evergreen Crossing And The LoftsIndianapolis, IN 2 of 5Grande Pointe Healthcare CommuRichmond Heights, OH 2 of 5Great Lakes Healthcare CenterDyer, IN 2 of 5Greenbrier Health CenterParma Heights, OH 2 of 5Hagerstown Healthcare CenterHagerstown, MD 2 of 5Hanover Healthcare CenterMassillon, OH 2 of 5Holly Hill Healthcare CenterTowson, MD 2 of 5Keyser Healthcare CenterKeyser, WV 2 of 5Mercer Healthcare CenterBluefield, WV 2 of 5Morgantown Healthcare CenterMorgantown, WV 2 of 5Mount Airy Nursing and Rehab CenterMount Airy, MD 2 of 5Petersburg Healthcare CenterPetersburg, VA 2 of 5Riverside Nursing And Rehabilitation CenterDayton, OH 2 of 5Rolling Hills Healthcare CenterNew Albany, IN 2 of 5Salem West Healthcare CenterSalem, OH 2 of 5Wedgewood Healthcare CenterClarksville, IN 2 of 5Westminster Rehabilitation and Wellness CenterWestminster, MD 2 of 5Wildwood Healthcare CenterIndianapolis, IN 2 of 5Worthington Healthcare CenterParkersburg, WV 2 of 5Wyant Woods Healthcare CenterAkron, OH

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 / managerTypeRoleShareSince
WV AMFM OP CO., LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/14/2023
ROMEO, DOMINICIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2023
STOLTZ, CHARLESIndividualCORPORATE OFFICERsince 04/14/2023
WILHEIM, RONALDIndividualCORPORATE OFFICERsince 04/14/2023
WILSON MGT CO., LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
BARKI, KELLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2023
GROVES, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/14/2023
MYERS, PAMELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
ODENTHAL, RICHARDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/22/2025

CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$5.6M
Net patient revenuemost recent cost report
+5.5%
Operating marginrevenue minus expenses
$544K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 89%Medicare 3%Other / private 9%

About 89% 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 $544K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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

$377per resident / day
operating cost
$11,457per month
≈ monthly operating cost
$399per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in West Virginia
$12,836/mo
Nursing home (semi-private)
$13,262/mo
Nursing home (private)
$6,340/mo
Assisted living

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 515125. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-04, 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.

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