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Clarksburg Healthcare Center

2096 Davisson Run Road, Clarksburg, WV 26301 · For profit - Corporation · 110 certified beds · (304) 624-6500 Medicare & Medicaid certified

Call the home — (304) 624-6500 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 20241 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$10,036 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)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,036 in federal fines (most recent 2024-10-17)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 33% of its spending goes to commonly-owned related companies

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) 3 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
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3 Hospital Plz · (304) 623-1330 · Call to confirm hours
Pharmacy
700 Oakmound Rd · (304) 848-5898 · Call to confirm hours
Grocery
Food Lion0.5 mi
1713 Milford St · (304) 623-3419 · Call to confirm hours
Park
1 Medical Center Dr · (304) 624-1655 · 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 4 of 5
Short-stay residentsrehab / post-hospital 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 fell from 4 to 3 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 rating3★
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 increased12.6%14.7%15.4%better
Long-stay residents who lose too much weight4.9%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.3%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 symptoms1.3%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 injury6.4%4.4%3.3%worse
Long-stay residents whose ability to walk worsened19.4%15.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.2%27.0%18.9%typical
Long-stay residents given the seasonal flu vaccine98.9%97.6%95.3%typical
Long-stay residents with pressure ulcers2.1%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control19.8%22.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table3.3%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 vaccine74.6%79.4%79.4%typical
Short-stay residents rehospitalized after admission14.5%22.5%22.6%better
Short-stay residents with an outpatient ER visit5.6%11.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.681.801.67typical
Long-stay outpatient ER visits per 1,000 resident days3.721.841.80worse

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.

35.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

35.3%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
57.7%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 57.7% 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 26 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 0.26 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 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF35.3%CMS range 27.1–46.851.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.4–16.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge34.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge38.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified62.2%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 worsened4.4%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 hospitalization8.2%CMS range 4.7–13.17.1%Oct 2023–Sep 2024no different from U.S.
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

0.60
RN hours/ resident / day
1.04
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.56
Total nurse hours/ resident / day
0.45
RN hoursweekends
37.2%
Total nursing turnover
11.1%
RN turnover

How full it usually is: this home is certified for 110 beds and averages 92.7 residents a day — about 84% occupied, or roughly 17 beds typically open. It usually has some room. 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.25 hrs/resident/day on weekends vs 3.69 on weekdays — 12% thinner on weekends. RN hours go from 0.66 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2026-05-05)
10
at the previous standard inspection (2024-10-17)

Deficiencies are unchanged from the previous inspection. 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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-10-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations and staff interview, the facility failed to ensure residents were provided with a safe environment to prevent elopement, resulting in Resident #41 leaving the facility. This failure to ensure residents did not exit the facility unattended on 07/11/2024 placed all at risk residents who could have exited the facility in an Immediate Jeopardy (IJ) situation. This will be cited at past noncompliance because the facility corrected the failure as of 07/09/24, prior to this survey. Resident Identifier: #41. Facility Census:96. The State Agency (SA) determined this Past Non_Compliance had the potential to cause serious injury, harm, impairment or death to occur. Past non compliance Immediate Jeopardy was issued on 10/16/24 at 3:32 PM. The past non compliance occurred on 07/11/24 and was corrected on 07/13/24. Findings included: a) Resident #41 On 07/11/24 Resident # 41 left the facility through an unsecured door and walked to the front returning to the facility. 1) Progress Notes 7/11/2024 01:12 Pt went out a side door and then walked to the front door.…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2026-05-05 · tag F0656 — failed to write and follow a full care plan — pattern
    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 on observation, record review and staff interview, the facility failed to develop and implement care plans for fall interventions, means of communication and multiple diagnoses. The failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #61 and #44. Facility Census: 88. a) Resident #5 - On 05/04/26, Resident #5's care plan was reviewed for fall precautions/interventions. The resident's care plan stated, Device: Non-skid strips to floor on the left side of bed. and Device: Nonslip material to wheelchair for safety. The resident's orders stated, DEVICE: DYCEM to wheelchair for safety every shift, and Device: Non-skid strips to floor on the left side of bed. On 05/04/26, the state surveyor observed Resident #5's room and wheelchair. There were no non-skid strips of tape on the resident's left side of the bed and Dycem was placed on top of the resident's wheelchair cushion. On 05/04/26 3:40 PM, Corporate Registered Nurse #101 confirmed there was no non-skid tape on the resident's left side of the bed and Dycem was on top 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-05 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, resident interview and staff interview, the facility failed to follow menus as posted, This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #31, #47 and #71. Facility Census: 88.Findings included: a) On 04/29/2026 at 11:52 AM, the menu posted at the entrance of the first-floor dining room stated: Cranberry Orange ChickenGarlic and [NAME] roasted Red Skin PotatoesDinner RollMandarin Oranges On 04/29/2026 at 11:52 AM, Nurse Aide #88 confirmed cabbage was not listed on the posted menu and cabbage was served to residents for lunch in the dining room. b) Resident #31 On 04/28/26 at 10:50 AM, during the initial interview, Resident #31 reported receiving chicken wings which were not on the menu for a couple of meals. c) Resident #47 On 04/29/26, Resident #47 received ravioli and cabbage which were not listed on the posted menu. Licensed Practical Nurse #77 confirmed that residents received ravioli and cabbage for the lunch meal. d) Resident #71 On 04/29/26, Resident #71 received ravioli 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-05 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The Facility failed to ensure residents were served meals timely on A Hall.During the annual survey process, the facility failed to ensure timely provision of meals in accordance with posted meal service times of 7:00 AM to 8:15 AM for Breakfast, 12:00 PM to 1:15 PM for Lunch, and 5:00 PM to 6:15 PM for Dinner.Observation revealed that at 9:40 AM on 5/5/26, residents on A Hall were still being served breakfast, significantly beyond the scheduled meal service window. Resident #74, identified as requiring feeding assistance, was still waiting for their meal at that time. During an interview, CNA #72 stated, This happens often, regarding delayed meal tray delivery from the kitchen. It was further reported that A Hall received meal trays around 9:00 AM. During an interview, the facility administrator stated, One hallway has to be last, when addressing the delayed meal service.Additionally, surveyor observation noted meal pass occurring on A Hall at approximately 9:40 AM. On 4/28/26 at 10:50 AM, Resident #31 expressed concern regarding consistently late meal service, stating, I fall…

    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 before2026-05-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review and staff interview, the facility failed to ensure staff hand hygiene was completed during the dining process. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 88.Findings included: a) The facility's policy and procedure for Standard Precautions stated that hand hygiene should be performed: A. Before eating/feeding or assisting in the dining room and tray pass. On 04/28/26 at 11:55 AM, during the dining room observation, Registered Nurse #75 did not use hand hygiene between residents while serving. Nurse Aide #72 and Registered Nurse #75 passed drinks to each other and then served the residents their drinks without performing hand hygiene. At 12:05 PM, Licensed Practical Nurse #33 confirmed the hand hygiene issues in the dining room.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-05 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident/family interviews, and record review, the facility failed to ensure patient care equipment, specifically mechanical lifts with frayed, taped wires, was maintained in safe operating condition. Resident identifiers: #21, #31, #9, #17, #75, #44, #45, #47, #13, #79, #29, #66, #105, #73, #82, #83, #16, #33, #63, #64, #68, and #84. Facility Census: 88. Findings included:a) On 04/29/26 at approximately 4:30 PM, a resident's family member spoke with the state survey team concerning an issue with the mechanical lifts. The Joerns' Hoyer Lifts, model [NAME]-PRESENCE-S) were an issue per the discussion. The family member stated the resident lifts were dirty and had electrical tape on them. They reported sometimes only one lift was in operating condition and was used between both floors.On 04/29/26 at 5:15 PM, the Survey Team inspected the lifts in the shower rooms on both floors. Both lifts had electrical tape on the wires attached to the cradle on both sides. The lift on the first floor had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-05 · 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, observation and staff interview, the facility failed to ensure physician's orders for fall preventions were followed. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #5. Facility Census: 88.Findings included:Resident #5 a) On 05/04/26, Resident #5's orders were reviewed for fall precautions/interventions. The resident's orders stated, DEVICE: DYCEM to wheelchair for safety every shift, and Device: Non-skid strips to floor on the left side of bed. On 05/04/26, the state surveyor observed Resident #5's room and wheelchair. There were no non-skid strips of tape on the resident's left side of the bed and Dycem was placed on top of the resident's wheelchair cushion instead of underneath it. On 05/04/26 at 3:40 PM, Corporate Registered Nurse #101 confirmed there was no non-skid tape on the resident's left side of the bed and Dycem was on top of the resident's cushion instead of underneath it to help prevent the cushion from sliding/slipping out of the wheelchair. Corporate Registered Nurse #101 confirmed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview and observation, the facility failed to ensure the residents' environment in the shower room was free from accident hazards on A Hall. This failed practice had the potential to affect a limited number of residents. Resident Identifier #39. Facility Census: 88.Findings included: a) Resident #39 On 04/29/26 at 6:09 PM, the state surveyor investigated the shower room on C Hall. Resident #39, a resident from D Hall, was in the bathroom adjacent to the shower room. The resident could open the door from the bathroom into the shower room. The shower door was locked with a keypad entrance. The bathroom door is not locked from the hallway. A gallon jug of Medco Prewash MP2017 was open and sitting on top of the wheelchair washer machine. According to the Safety Data Sheet (SDS), the product is labeled: H315 Causes skin irritation and H319 Causes serious eye irritation. This was a random opportunity for discovery. Licensed Practical Nurse #42 confirmed the bottle of cleaner was open and in the shower room. The gallon jug of Medco Prewash MP2017 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
  • Potential for harm · D2026-05-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, 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 dispose of an expired vial of insulin for Resident #11 on the B medication cart. This was a random opportunity for discovery. Resident Identifier: #11. Facility Census: 88.Findings Include: a) Resident #11 On [DATE] at 9:10 AM, the medication cart on B hall was checked for the care area of medication storage. An expired vial of Lispro insulin for Resident #11 was found. Licensed Practical Nurse (LPN) #77 verified the insulin vial expired on [DATE]. The vial's opening date was noted as [DATE]. On [DATE] at 9:14 AM, the Director of Nursing (DON) was notified and confirmed that insulin expired 28 days after the vial is opened.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-05 · tag F0807 — failed to offer suitable drinks — isolated
    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 — the official record, unedited, may be distressing

    Based on observation, resident interview and staff interview, the facility failed to ensure drinks including water and other liquids were served consistent with residents' needs and preferences. This failed practice had the potential to affect a limited number of residents, Resident Identifier: #12. Facility Census: 88.Findings included: a) Resident #12 On 04/28/26 at 12:15 PM, during the dining room observation on the first floor of the facility, Resident #12's tray card stated, Hot Coffee - 6 Oz. Resident #12 did not receive hot coffee as printed on the tray card. When the state surveyor asked the resident if she wanted coffee, the resident stated, Yes, I wanted coffee. The resident received coffee following surveyor intervention. On 04/28/26, Licensed Practical Nurse #33. confirmed the resident did not receive coffee as printed on the tray card. The facility's policy and procedure for Dining and Food Preference stated, Individual dining, food and beverage preferences are identified for all residents and patients.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-05 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and staff interview, the facility failed to ensure residents received therapeutic diets as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #5 and #35. Facility Census: 88.Findings included: Resident #5 On 04/28/26, Resident #5's tray card was reviewed. The residents' tray card stated, Dys Mech - Regular and Pureed Buttered Dinner Roll - #16 Scp. The resident received a whole, unbuttered roll with the lunch meal. Resident #5's diet order stated, Regular Diet Dys Mech texture, Nectar Thickened Liquids consistency. Resident #35 On 04/28/26, Resident #35's tray card was reviewed. the residents tray card stated, Dys Mech - Regular and Pureed Bettered Dinner Roll - #16 Scp. Resident #35's diet order stated, Regular diet Dys Mech texture, thin liquids consistency, for diet. At 12:10 PM, Registered Dietician #20 confirmed Resident #5's and Resident #35's tray cards stated Dysphagia Mechanical Soft Diet with pureed buttered dinner roll - #16 scoop and that the residents did not…

    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
Show the remaining 19 citations
  • Potential for harm · Ecited before2025-11-13 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and observation the facility failed to provide meals at a scheduled time. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 96. Findings included:a) Meal times During a complaint investigation for Residents not being served meals on time meals found Resident Council Minutes: May 13, 2025-Meals are late. The kitchen already gets rid of left overs or are running out of main selection. Residents are unable to get an alternate. June 10, 2025- Meals continue to coming out late especially at dinner. Staff are rushing residents to eat and it is running into evening activities. July 8,2025-Meals continue to coming out late and it is running into activities.August 12, 2025 - Meals continue to coming out late especially at dinner. Staff are rushing residents to eat and it is running into evening activities.September 9, 2025-Residents wants consistency with quality of meals and times that meals are served. October 14, 2025- Meals are late especially at dinner. Sometimes trays are missing.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-17 · tag F0657 — failed to keep the care plan current — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to revise a care plan regarding a fall with major injury for Resident #47, behaviors and the discontinuation of medications for Resident #51, and the code status of Resident #50. This is true for three (3) of 24 residents reviewed during the survey process. Resident Identifier: #47, #51 and #50. Facility Census: 96. Findings Included: a) Resident #47 On [DATE] at 12:15 AM, the care plan was reviewed for Resident #47. The review found the care plan had not been revised to indicate a fall with major injury had occurred on [DATE]. A progress note dated [DATE] at 0000 by the facility nurse practitioner states the following: Post fall with head injury History Of Present Illness: [DATE] This is an (Age and sex redacted) being seen after sustaining a fall. Provider was in the building when the fall occurred. I arrived to the bedside Staff had assisted resident back to her bed. She had hit her head on the floor. There was already bruising forming and edema…

    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 · E2024-10-17 · 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 store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. FACILITY: FACILITY Facility Census: #96. Findings included: Findings confirmed by the Dietary Manager(DM) on 10/14/24 during kitchen investigation initiated at 11:45 AM included: a) Large container of tea with no date/smeared date (not legible). Kitchen staff (#27), stated, That was yesterday's. SS reviewed with DM. The DM stated, That's made every day. Measuring cup with tea on the bottom was sitting on top of the container. Tea was relabeled with current date prior to end of the kitchen tour. b) Pitchers were stored on a shelf with water inside x 2. DM stated there was a limited amount of space to properly store items in the kitchen. c) [NAME] cake mix was opened on 08/17/24- not sealed and spilling out of bag- no use by date was marked. d) Dented can x 1 - Campbell's chicken noodle soup. e) Devil's Food Cake mix opened on 09/29/24- sealed-no…

    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 before2024-10-17 · 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 and staff interviews, the facility failed to have an accurate medical record for three (3) of 24 residents reviewed during the Long Term Care Survey. Resident identifier: #294, #9, #76. Facility Census: 96. Findings Included: a) Resident #294 On 10/14/24 at 12:00 PM surveyor observed a sign posted being Resident #294's bed stating no blood pressure (B/P) or labs in left arm). During record review on 10/15/24 at approximately 10:00 AM of Resident #294's orders showed an order to check fistula in left arm for bruit and thrill every shift. Further record review on 10/15/24 revealed the following: - Facility staff documented on 10/04/24, 10/05/24, and 10/12/24 B/P was obtained in Resident #294's left arm. - The care plan did not address or contain anything about not taking the blood pressure or labs in the left arm, and did not identify Resident #294 as having a fistula in the left arm. An interview on 10/15/24 at approximately 1:00 PM with the Director of Nursing (DON) confirmed the care plan did not address Resident #294 as having an fistula in the left arm 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-17 · 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, record review and staff interview, the facility failed to maintain an infection control program during medication administration. This had the potential to affect more than a limited number of residents. This is a random opportunity for discovery. Facility Census: 96. Findings Included: a) Medication Administration On 10/16/24 at 8:45 AM, an observation of Licensed Practical Nurse (LPN) #51 during medication administration on B hall was completed. There are 22 residents who reside on the B hall. LPN #51 was assigned the entire B hall for medication administration. On 10/16/24 at 8:57 AM, LPN #51 failed to complete hand hygiene between Resident #32 and Resident #2. On 10/16/24 at 9:35 AM, LPN #51 left the B Hall to go the medication room. Upon return, LPN #51 did not complete hand hygiene prior to administering medication to Resident #37. On 10/16/24 at 9:55 AM, an interview was held with LPN #51. LPN #51 stated, I thought I did hand hygiene at these times. On 10/16/24 at 10:00 AM, the Director of Nursing (DON) was notified of the failure to complete hand…

    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 · D2024-10-17 · 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

    Based on record review and staff interview the facility failed to notify the Medical Power of Attorney of abnormal testing results. Resident Identifier: #145 Facility Census: #96 Findings included: a) Resident #145 On 10/16/24 at 2:10 PM record review shows that Resident #145 had abnormal laboratory and urinalysis results that were not relayed to the Medical Power of Attorney (MPOA). According to the Mayo Clinic: A complete blood count (CBC) is a blood test. It's used to look at overall health and find a wide range of conditions, including anemia, infection and leukemia. The normal white blood cell count range is typically between 4 and 11 depending on age and medical conditions. Review of a Complete Blood Count (CBC) laboratory results collected on 12/29/23 and printed on 12/30/23 shows an abnormal white blood count (WBC) of 27.6. There are additional test results on the laboratory report that are flagged as abnormal. The urinalysis is also marked as abnormal and containing white blood cells and bacteria. There is no documentation that the MPOA was informed of the testing results.…

    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 · D2024-10-17 · 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 observation, resident and staff interview, facility record review, and medical record review, the allegation that the facility failed to ensure that residents were free from abuse and neglect is found to be substantiated. This was true for Residents #16, #34, and #11. Facility census: 96. Findings included: a) Resident #16 On 10/16/2024 a review of the Facility Reported Incident (FRI) which occurred on 09/05/24 and found Resident #16 saturated with a ring of urine staining the bed linens, street clothes and shoes. The report specified that initially the resident was angered about the incident, but afterward placed the incident behind him and was doing better. The witness statement submitted by CNA #119 and undated read as follows: When I arrived on shift [Resident #16] was one of my first residents I checked on. I got him ready for bed, toileted him, offered to change his clothes. He didn't want to be layed down. I later returned with snacks and ice water and I got him a tea. I did regular rounds also, then around 3:30-4:00 AM, he rang was hungry so I got him and his room…

    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 · Dcited before2024-10-17 · 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 on record review, resident interview and staff interview, the facility failed to develop a person-centered comprehensive care plan for Resident #80 regarding the use of hearing aids, and not having careplaned Resident #294 having fistula in left arm. This is true for one (1) of 24 residents reviewed during the survey process. Resident identifier: #294. Facility Census: 96 Findings included: a) Resident #294 On 10/14/24 at 12:00 PM surveyor observed a sign posted being Resident #294's bed stating no blood pressure(B/P) or labs in left arm) During record review on 10/15/24 at approximately 10:00 AM of Resident #294's orders showed an order to check fistula in left arm for bruit and thrill every shift. Further record review on 10/15/24 revealed the following: - Facility staff documented on 10/04/24, 10/05/24, and 10/12/24 B/P was obtained in Resident #294's left arm. - The care plan did not address or contain anything about not taking the blood pressure or labs in the left arm, and did not identify residents having a fistula in the left arm. An interview on 10/15/24 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 · Dcited before2024-10-17 · 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 interview, the facility failed complete a change of condition for a declining resident and caused a delay in treatment for a resident. Resident Identifiers: #50 and #145. Facility Census: #96. Findings included: a) Resident # 50 On 10/14/24 at 2:16 PM record review shows Resident #50 had several orders and progress notes dated 10/05/24 concerning her condition. The following details were reviewed in the nurses progress notes: 10/5/2024 18:24 Nurses Note Note Text: Resident decline in ability to consume Po intake. Resident is gagging with the touch of food in her mouth. This nurse contacted (in house physician). He gave recommendations for care and resident Medical Power of Attorney (MPOA) declined further testing. MPOA stated I do not feel like anything is wrong, I think she is just tired. This nurse talked to MPOA about the use of morphine and educated MPOA on comfort focused treatment. MPOA changed resident post form to DNR-CC. MPOA in agreement with new order and is sitting at resident bedside. 10/5/2024 17:58 Nurses Note Note Text: New order per…

    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 before2024-10-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility record review, medical record review, and staff interview, the allegation that the facility failed to ensure nutrition and hydration status maintenance for Resident #295 was substantiated. Facility census: 96. Findings included: On 10/16/24 the surveyor reviewed an initial reporting form submitted as a Facility Reported Incident (FRI) which occurred and was reported on 04/17/24. This FRI indicates that LPN #85 stopped Resident #295's ordered tube feeding on night shift 04/17/24 stating that the tube feed was stopped because it didn't flush well. At this time the Nurse Practitioner (NP) was notified and the tube feeding was restarted during the day shift of 04/17/24 with additional supplements. According to the five-day followup, the facility administration notified Resident #295's health care surrogate at 11:20 AM on 04/17/24. Additionally, administration reported the event to the LPN Board and the Ombudsman at 10:29 AM. The report indicates that the resident was not interviewable. The followup…

    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 · D2024-10-17 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to store the residents' personal food in a way that was separate or easily distinguishable from facility food. This failed practice has the potential to affect more than a limited number of resident's. FACILITY:FACILITY Facility Census: #96. Findings included: Finding confirmed by the Dietary Manager(DM) on 10/15/24 during the kitchen investigation initiated at 11:45 AM included: a resident's food item found in the facilities main freezer in the kitchen. An opened box of popcorn shrimp in the facility freezer was not dated or labeled. The DM stated the item was a resident's personal item and there was no room in the resident's freezer for the frozen food.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-11 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident specifically premeal activities not being provided. This was a random opportunity for discovery. Facility census: 82. Findings included: a) Dining observations An observation of meal service on 01/09/23 from 11:30 AM to 11:50 AM, found 19 residents sitting with eight (8) Residents sleeping in the C and D hall dining room, waiting for their noon meal. No activities provided. A second observation of the C and D hall dining room on 01/10/23 at 11:00 AM found 10 Resident's sitting around the room with no staff or activities be provided. A third observation of meal service on 01/10/23 from 11:25 AM to 11:43 AM, found 16 residents sitting with six (6) Residents sleeping in the C and D hall dining room, waiting for their noon meal. No activities being provided. During an Interview on 01/10/23 at 11:45 AM with the Activities Director confirmed, staff should be present in the dining room providing premeal…

    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 · E2023-01-11 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents residing in the facility. Facility census: 82. Findings included: a) Garbage and refuse disposal On 01/10/23 at 12:45 PM, observation was made of the garbage dumpster located on the facility grounds. The lid to the dumpster was not closed. Additionally, a white trash bag containing garbage was lying on the ground beside the dumpster. These deficient practices were confirmed by the Administrator on 01/10/23 at 12:50 PM. No further information was provided through the completion of the survey. .

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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, policy review, resident interview, and staff interview, the facility failed to ensure a residents' right to formulate an advance directive. This was true for one (1) of 24 resident's reviewed in the Long-Term Care Survey Process. Resident identifier: #7. Facility census: 82. Findings included: a) Resident #7 On 01/09/23 at 1:28 PM, a brief record review revealed the following details: --Resident #7 was admitted to the facility on [DATE]. --Resident #7 had capacity to make her own decisions. --There was a Physician Orders for Scope of Treatment (POST) form on file, completed on 12/13/22, which indicated no advance directive in existence. During an interview on 01/10/23 at 11:30 AM, Social Worker #70 reported she specifically remembered going over paperwork with Resident #7 and discussing resident's right to formulate a medical power of attorney if she desired. Social Worker #70 stated she would check with the medical records department to locate the paperwork that would have been signed…

    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 · D2023-01-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed under closed records during the Long-Term Care Survey Process (LTCSP). The MDS assessment for Resident #85 did not accurately reflect the resident's discharge status. Resident identifier: #85. Facility census: 82. Findings included: a) Resident #85 On 01/10/23 at 12:41 PM, a review of the electronic medical record was completed. A review of the Discharge MDS, with an Assessment Reference Date (ARD) of 11/03/22, revealed Section A was marked as Resident #85 being discharged to an acute hospital. However, the discharge plan documentation, dated 11/02/22, noted resident was scheduled for a discharge to home. During an interview on 01/10/22 at 2:12 PM, the MDS Coordinator confirmed Resident #85 was discharged to home. The MDS Coordinator noted the MDS coding reflecting a discharge to an acute hospital was in error. .

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · 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 resident interview, record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was true for two (2) of 24 sample residents reviewed during the Long Term Care Survey Process. Resident #9 had no order for a pressure reducing device and Resident # 26 had no repeat laboratory (lab) work obtained. Resident identifiers: #9 and #26. Facility census: 82. Findings included: a) Resident #9 During the resident interview with Resident #9 on 01/09/23 at 11:47, stated the air mattress worked well to keep her repositioned, since she was unable to move due to her multiple sclerosis (MS). A medical record review on 01/10/23 revealed the current care plan had an intervention developed on 05/17/22 for a pressure reducing device on bed at all times for pressure ulcer risk. Further record review indicated there was no physician's order obtained for the pressure reducing air mattress. In an interview with the Director of Nursing (DON) on 01/10/23 at 2:05 PM, verified there was no physician's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on resident interview, record review and staff interviews the facility failed to provide the proper hemodialysis diet. This was true for one (1) of one (1) resident reviewed for dialysis during the Long Term are Survey Process. The physician's orders for dietary restrictions were not being followed for Resident #61. Resident identifier: #61. Facility census: 84. Findings included: a) Resident #61 During the resident interview on 01/09/23 at 11:56 AM, Resident #61 reported she is often served soups, which she was not to have due to fluid restrictions. A record review completed on 01/10/23, revealed a physician's order for no soups to limit fluid intake with a start date of 11/21/2022. A review of resident's meal ticket did not indicate no soups to limit fluid intake. In an interview with the Dietary Manager on 01/10/23 at 2:50 PM, reported the order for no soups due to fluid intake was not under the proper dietary category, which explained why the order was not included in the dialysis diet. .

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review and staff interview, the facility failed to follow physician's orders in accordance with professional standards of practice. This was true for two (2) of two (2) residents reviewed for the care area of respiratory care. Resident identifiers: #27 and #31. Facility census: 82. Findings Included: a) Resident #27 On 01/09/23 at 11:20 AM, the oxygen setting on the concentrator was 1.5 liters per minute (LPM). A physician's order dated 11/16/22 was for the oxygen setting of 2 LPM. Licensed Practical Nurse (LPN) #2 confirmed the setting of the oxygen was incorrect for Resident #27. LPN #2 corrected the setting. b) Resident #31 On 01/09/23 at 11:22 AM, the oxygen setting on the concentrator was 2.5 LPM. A physician's order dated 08/26/22 was for the oxygen setting of 2 LPM. LPN #2 confirmed the setting of the oxygen was incorrect for Resident #31. LPN #2 corrected the setting. No further information was obtained during the survey process. .

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · 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 — the official record, unedited, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, a post form was not completed accurately. This was true for one (1) of 24 Residents reviewed during the Long-Term Care Survey Process (LTCSP). Findings included: a) Resident #19 Record review on 01/10/23, revealed: Section E (Patient/Resident, Guardian/ MPOA Representative) was not completed with a Signature on Resident #19's active Physician Order for Scope of Treatment Form (POST Form). Verbal Consent with the Medical Power of Attorney' name was written in this section with the date 04/11/2022. During an interview on 01/10/22 at 1:11 PM the Social Worker Director, confirmed Resident #19's POST form was inaccurate with section E incomplete without a Resident representative's signature. .

    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

$10,036 in federal fines across 1 penalty.

  • $10,036 — penalty dated 2024-10-17

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 3 of 52.6+0.4 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
RCA NH HOLDINGS OP CO., LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/14/2023
GROVES, DONNAIndividualCORPORATE OFFICERsince 04/14/2023
ROMEO, DOMINICIndividualCORPORATE OFFICERsince 04/14/2023
STOLTZ, CHARLESIndividualCORPORATE OFFICER; TRUSTEE OF THE SNFsince 04/14/2023
WILHEIM, RONALDIndividualCORPORATE OFFICER; TRUSTEE OF THE SNFsince 04/14/2023
DAVISSON RUN MGT CO., LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
BARNETTE, JOSHUAIndividualOPERATIONAL/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
C.R. STOLTZ FAMILY INVESTMENT COMPANY INCOrganizationADP OF THE SNFsince 04/14/2023
C.R. STOLTZ IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
HEALTH CARE HOLDINGS, LLCOrganizationADP OF THE SNFsince 04/14/2023
I. ROSEDALE FAMILY INVESTMENT COMPANY INCOrganizationADP OF THE SNFsince 04/14/2023
I. ROSEDALE IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
MARANTZ WV HOLDINGS, LLCOrganizationADP OF THE SNFsince 04/14/2023
R.S. WILHEIM IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
RCA HEALTHCARE HOLDINGS, LLCOrganizationADP OF THE SNFsince 04/14/2023
RONALD S WILHEIM 2012 SPOUSAL TRUSTOrganizationADP OF THE SNFsince 04/14/2023
ROSEDALE FAMILY INVESTMENT COMPANY, INCOrganizationADP OF THE SNFsince 04/14/2023
RRW, LLCOrganizationADP OF THE SNFsince 04/14/2023
S.L. ROSEDALE IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
WILHEIM FAMILY INVESTMENT COMPANY, INC.OrganizationADP OF THE SNFsince 04/14/2023

CMS files one row per role, so the 25 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

15 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.

$9.7M
Net patient revenuemost recent cost report
+2.0%
Operating marginrevenue minus expenses
$3.2M
Related-party expense33% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 6%Other / private 11%

About 83% 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 $3.2M paid to related parties — landlords or management companies under common ownership — equal to about 33% 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

$403per resident / day
operating cost
$12,257per month
≈ monthly operating cost
$411per 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 515166. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-05, 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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