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Minnie Hamilton Health Care

186 Hospital Drive, Grantsville, WV 26147 · Non profit - Corporation · 24 certified beds · (304) 354-9244 Medicaid only — no Medicare

Call the home — (304) 354-9244 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20243 actual-harm citations
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • 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 Jun 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • 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

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 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
(304) 927-1495 · Call to confirm hours
Pharmacy
337 Main St · (304) 354-9232 · Call to confirm hours
Grocery
201 S Calhoun Hwy · (304) 354-6626 · Call to confirm hours
Park
(304) 354-0032 · 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 3 of 5
Long-stay residentspeople who live here 3 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 1 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 increased14.7%14.7%15.4%typical
Long-stay residents who lose too much weight14.0%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection5.7%1.6%2.0%worse
Long-stay residents with depressive symptoms4.5%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 injury2.3%4.4%3.3%better
Long-stay residents whose ability to walk worsened3.4%15.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.8%27.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%97.6%95.3%typical
Long-stay residents with pressure ulcers5.2%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control18.5%22.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table34.2%13.4%17.1%worse

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.

0.16U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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 SNFnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
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 — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.

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

0.75
RN hours/ resident / day
0.98
LPN hours/ resident / day
2.60
Aide hours/ resident / day
4.33
Total nurse hours/ resident / day
0.83
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 24 beds and averages 22.9 residents a day — about 95% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.33 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 is at or above 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 3.68 hrs/resident/day on weekends vs 4.59 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

5
deficiencies at the latest standard inspection (2025-08-14)
16
at the previous standard inspection (2024-06-27)

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.

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2024-06-27 · 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 record review and staff interview, the facility failed to ensure a resident was not neglected. The facility failed to provide services to a resident that was necessary to avoid physical harm. This was true for 1 (one) of 1 (one) resident's reviewed during the Long Term Survey Process. Resident #8 had an area on her breast that had not been identifeid by the facility. The resident suffered actual physical harm. The facility had not identified this as an area that needed assessed despite showering and dressing the resident daily. The area on the resident's breast was biopsied by a determatorly group and diagnosed as melanoma. Facility census: 24. Resident identifier: #8. Findings included: a) Resident #8 A medical record review for Resident #8 revealed Resident #8 and Resident #8's MPOA had attended a dermatology appointment on 03/21/24. The appointment was for skin irritations on Resident #8's face. During the appointment, Resident #8 questioned if the Dermatologist should look at the spot on her breast. This resulted in a biopsy being performed on her left breast with a…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-06-27 · 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 to provide services to a resident that was necessary to avoid physical harm. This was true for 1 (one) of 1 (one) resident's reviewed during the Long Term Survey Process. Resident #8 had an area on her breast that had not been identifeid by the facility. The resident suffered actual physical harm. The area on the resident's breast was biopsied by a determatorly group and diagnosed as melanoma. Facility census: 24. Resident identifier: #8. Findings included: a) Resident #8 A medical record review for Resident #8 revealed Resident #8 and Resident #8's MPOA had attended a dermatology appointment on 03/21/24. The appointment was for skin irritations on Resident #8's face. During the appointment, Resident #8 questioned if the Dermatologist should look at the spot on her breast. This resulted in a biopsy being performed on her left breast with a diagnosis of melanoma. On 03/25/24 Resident #8's daughter spoke with the facility DOQA (Directof of Quality Assurance) stating, she was upset that no one mentioned the place on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-06-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed prevent the development of pressure ulcers/injuries (PU/PI's) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development and promote the healing of existing pressure ulcers/injuries. The physician elected This was true for 1 (one) of 2 (two) residents reviewed for the Long Term Survey Process. Facility census: 24. Resident identifier: #11. Findings include: a) Resident #11 During the review, Resident #11's record a care plan was noted with a start date of 01/31/24. The care plan revealed the resident was at high risk for skin breakdown. The reisdent was incontinent of bowel and bladder and was dependent upon staff for activities of dialy living. The care plan goal was that the resident would not develop impaired skin for the next three (3) months. The appraoches to acheive this goal and resolve this probelm were as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-14 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, Resident Council interview, and staff interview the facility failed to ensure residents know how to file a grievance and could do so anonymously if they desired. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census 23.Findings Include:a)Resident CouncilDuring the Resident council meeting on 08/12/25 at 10:30 AM, The Resident Council as a whole said that they did not know how to file a grievance.An observation on 08/12/2025 at 11:06 AM, revealed that there are no grievance forms readily available to residents on the unit.During an interview on 08/12/25 at 11:10 PM, The Activity Director (AD) went behind the nurses station and pulled a concern form out of the file cabinet and stated, I didn't know these had to be available for residents to get on their own. I will get something to put them in and get them put out for the residents to get.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-14 · 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 — the official record, unedited, may be distressing

    Based on observation and staff interview the facility failed to treat each resident with respect and dignity during a meal. This is a random opportunity of discovery. Resident Identifier: #14. Facility Census: #23. Findings Include: a) Resident #14 On 08/12/2025 at 12:23 PM Certified Nurse Aide (CNA) #28 was observed standing in the dining room assisting Resident #14 with her lunch meal. When the CNA was told she can not stand and assist a resident with meals, she stated I can't get a chair in here. I replied that she can move the resident if needed but she can not stand, it is a dignity issue. She obtained a chair and assisted the resident. This was confirmed with Cheif Exeucitive Officer on 08/12/2025 at 1:15 PM.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · 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 observation, record review, and staff interview the facility failed to develop/implement a care plan related to hand rolls for contractures. This failed practice was found true for (1) one of 12 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifier #16. Facility Census 23.Findings Include:a)Resident #16An observation on 08/11/25 at 2:50 PM, revealed that Resident #16 had contractures to both left and right hands.A record review on 08/11/25 at 3:30 PM, of Resident #16's order shows an order that reads as follows: Hand rolls to both hands due to immobility, contractures, and seizures.An observation on 08/12/25 at 9:00 AM, revealed Resident #16 in his room watching television in his Geri Chair. Resident did not have hand rolls in place as ordered by the physician.A record review on 08/12/25 at 10:30 AM revealed a care plan dated 07/09/25 for Resident #16 that reads as follows:Problem: (Resident #16 name) demonstrated no signs or symptoms of pain during the interview process, but does have multiple contractures, poor postures,…

    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 before2025-08-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to follow Physicians orders for neurological checks for unwitnessed falls and hand rolls for a resident. These findings were true for one (1) of three (3) residents reviewed during the Long Term Survey Process for falls. Resident Identifier: #10 and #16. Facility Census: #23. Findings Included: a) Resident #10 On 08/13/25 at 1:48 PM record review shows Resident #10 had an unwitnessed fall on 4/29/25 at 10:30PM (Event ID# WJX19620431). It is documented that Resident was noted to be on knees beside bed holding onto blanket. Pad on bed hanging on side of bed and wedge on floor. With each sound of thunder the resident was noted to jump and grab for nurse. Severe thunderstorms in area at time of fall. According to the event summary it states at approximately 10:30 PM resident was found rocking up onto her knew beside the bed, with a blanket being held by her. The pad on the bed was hanging off the side and the wedge was on the floor, every…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-14 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview the facility failed to promptly provide and/or obtain from an outside resource routine and emergency dental services to meet the needs of medicaid funded residents. This failed practice was found true for (1) one of (1) one resident reviewed for dental during the Long-Term Care Survey Process. Resident identifier #2. Facility Census 23.Findings Include:a)Resident #2The initial observation on 08/11/25 at 1:13 PM, revealed Resident #2 lying in bed. Residents' teeth appear to be broken off with the gum line.A record review on 08/12/25 at 1:54 PM, revealed a dental assessment worksheet completed on 05/16/24 and 08/12/24 marked as the Resident #2 having no problems with his teeth and/or gums.Further record review revealed a dental assessment worksheet completed on 05/01/25, marked yes for obvious cavities and yes for inflamed or bleeding gums.An readmission assessment dated [DATE] is marked that Resident #2 has his own teeth, and has inflamed gums. A record…

    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 · F2024-06-27 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    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 and staff interview, the facility failed to implement adverse event monitoring, and failed to implement performance improvement program activities that focus on quality of care. This was discovered during the long term care survey process and had the potential to affect all of the residents. Census 24. Findings included: a) Resident #8 - Adverse Event Monitoring 06/24/24 at approximately 1:15 PM a review was completed of a facility complaint. During the interview process of this complaint, the Medical Power of Attorney (MPOA) of Resident #8 was interviewed and the following letter was provided that the MPOA had received from the Director of Quality Assurance (DOQA) dated 04/01/24. The letter read as follows: This letter is a follow up to your concern received on March 25, 2024, in which you expressed concern about an area found on your mother ' s breast during a recent dermatology visit. As a result of your concern, a thorough review has been performed. The following is a summary of our…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-27 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility failed to maintain a quality assessment and assurance committee. This was discovered during the review of the facilities Quality Assurance Assessment committee during the Long Term Care survey Process. The Medical Director/designee and the Administrator did not attend the meetings. has the potential to affect all of the residents. Identifiers: Medical Director, Administrator. Facility Census: 24 Findings included: a) Medical Director/designee On 06/26/24 at 10:45 AM during an interview with the DON regarding the attending signatures for the Quality Assurance Meetings, the DON stated the Chief Nurse Officer (CNO) was the medical director designee. The DON also stated that the CNO served as the Infection Control Nurse for the long term care and attends the meeting as the Infection Control nurse in addition to the Medical Director designee. During the review of the CMS guidelines, that states the Medical Directors designee must not be another required member. The DON and that the Infection Control Nurse are required members. The CNO would not be able to complete the dual…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-27 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to develop and implement written policies and procedures to prohibit and prevent neglect and for these written policies to include the following components. This practice had the potentail to affect more than an isolated number of residents. Facility census: 24. Resident identifier: #8. Findings include: a) Resident #8 On 06/24/24 at approximately 1:15 PM, a review was completed of a facility complant regading Resident #8. The complaint included a letter received from the Director of Quality Assurance (DOQA) dated 04/01/24. The letter read as follows: This letter is a follow up to your concern received on March 25, 2024, in which you expressed concern about an area found on your mother's breast during a recent dermatology visit. As a result of your concern, a thorough review has been performed. The following is a summary of our findings: 1) Staff failed to appropriately recognize and document the area that is on your mother's breast that 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-27 · 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 create/revise a care plan for Resident #8 with a new diagnosis of depression which was severe with psychotic symptoms. Resident #11 had newly developed pressure areas. The care plan was not updated to identify the approaches and intervention being used for the healing of those pressure areas. Facility Census: 24. Resident identifiers: #8 and #11 Findings include a) Resident #8 06/26/24 01:15 PM 06/24/24 03:48 PM record review revealed resident was admitted [DATE] with a correct PASARR, and on 08/07/17 Resident #8 received a diagnosis of major depressive disorder , recurrent, sever with psychotic symptoms. on 8/03/17 06/26/24 01:16 PM no new PASARR was created after diagnosis of major depressive disorder , recurrent, severe with psychotic symptoms. On 8/03/17 and was not addressed in the care plan 06/26/24 01:25 PM Director of nursing confirmed the care plan was not updated to address the major depressive disorder. b) Resident #11 On 06/25/24 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 · E2024-06-27 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and observation the facility failed to maintain a medication error rate less than 5 %. Med error rate 7.41%. This was true for 2 (two) of 5 (five) residents observed during the Long-Term Survey Process. Facility census: 24. Resident identifiers: Resident #7, Resident #15. Findings include: a) Resident #07 On 06/26/24 at 06/26/24 11:06 AM, this Surveyor observed LPN #51 administer a percutaneous endoscopic gastrostomy (PEG) tube feeding. The physician's order was as follows: Administer Jevity 1.5 237 ml via PEG tube, gravity feed four times daily with 110 milliliters (ml) water flushes before and after each feeding. This provides the resident with 948 ml formula, 1420 kilocalorie's (kcal's) (27kcals/kilograms (kg)), 60g protein (1.2 grams (g)/kg), 720 ml free fluids, 880 ml flush for total of 1600 ml. LPN #51 was noted to aspirate the PEG tube to check for correct placement. After LPN #51 was noted to administer the following: (1) 7 ounces (oz) cup water (1) bottle of Jevity 1.5 8 oz (237 ml) (1) 7 oz cup water After completing feeding, this Surveyor…

    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
Show the remaining 17 citations
  • Potential for harm · Ecited before2024-06-27 · 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 — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to ensure pans were being stored properly. A random opportunity for discovery found wet pans stacked together. This failed practice had the potential to affect more than a minimum number of residents residing in the facility. Facility Census: 24. Findings included: a) During an observation in the kitchen on 06/24/24 at approximately 1:00 PM, Dietary Manager #9 pulled three (3) pans that were stored after being washed and sanitized. The pans appeared to be wet and were not dried before being stored. During an interview on 06/24/24 at approximately 1:05 PM Dietary Manager #9 confirmed the pans should have been dried before being stored let me get these re-washed and educate my staff on ensuring pans are dried before stacking them and storing them.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-27 · 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 and staff interview the facility failed to ensure safe cleaning and disinfection of resident care equipment (glucometers). The glucometers were shared among residents according to the manufacturers recommendations. The glucometer was used on 11 of 24 residents on the unit. Facility census: 24. Findings include: a) Facility On 06/26/24 at approximately 10:00 AM, a medication administration observation was made with Licensed Practical Nurse (LPN) #51. At that time, LPN #51 performed a blood glucose test on Resident #15 using a glucometer that shared among facility residents. After completion LPN #15 was noted to take a packet from the medication cart, take the towelette from the packet and wipe off the glucometer with it and immediately started to place it back in the charging station. At that time, this Surveyor asked LPN #15 what product she was using on the glucometer. LPN #15 responded she was using an alcohol pad. This Surveyor questioned LPN #15 related to dwell time of the alcohol pad to which she responded that she was unsure. On 06/26/24 at approximately…

    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 · D2024-06-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — the official record, unedited, may be distressing

    The facility failed to have the Ombudsman information posted for wheel chair residents to easily read. This was a random observation. Facility census: Findings included: On 06/25/24 at 11: 14 AM found the Board of Notice for Resident's Rights and Ombudsman information was located to high for residents to be able to see and read. An interview with Nurse Aide/ Activity Director (NA/AD) #27 confirmed the Board of Notice was hung to high for residents in wheel chairs to be able to see and/or read. In an interview on 06/26/24 at 10:23 AM with the Director of Nursing (DON) stated that she understood the Board of Notice was hanging to high for residents to be able to see.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and staff interview, the facility failed to ensure all alleged violations of neglect are reported to the appropriate state agencies. This was true for 1 (one) of 1 (one) resident's reviewed during the Long Term Survey Process. Facility census: 24. Resident identifier: Resident #8 Findings included: a) Resident #8 On 06/24/24 at approximately 1:15 PM, a review was completed of a facility complaint made the Medical Power of Attorney (MPOA) of Resident #08. The MPOA included, with the complaint, a letter she had received from the Director of Quality Assurance (DOQA) dated 04/01/24. The letter read as follows: This letter is a follow up to your concern received on March 25, 2024, in which you expressed concern about an area found on your mother's breast during a recent dermatology visit. As a result of your concern, a thorough review has been performed. The following is a summary of our findings: 1) Staff failed to appropriately recognize and document the area that is on your…

    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 · D2024-06-27 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and observation the facility to ensure that each resident who experienced a significant change in status was comprehensively assessed using the Center for Medicare and Medicaid Services (CMS) specified Resident Assessment Instrument (RAI) process. Resident #11 experienced a significant weight loss while receiving enteral feedings and developed two (2) pressure ulcers. This was true for 1 (one) of 24 residents reviewed for the Long Term Survey Process. Resident identifier: #11. Facility census: 24. Findings included: a) Resident #11 Resident #11 was admitted on [DATE]. Diagnoses included Diabetes Mellitus, Dementia, Depression, Schizophrenia and lung disease. A Brief Interview of Mental Status (BIMS) could not be performed as the resident was rarely understood or answer. 1. Pressure Ulcers On 06/25/24 at approximately 12:00 PM, a review of Resident #11's medical record was performed. During the review, Resident #11 was noted to have a care plan with a start date of 01/31/24…

    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 · D2024-06-27 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — the official record, unedited, 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 and new Preadmission Screening and Resident Review (PASARR) was not completed for a resident having a new medical diagnosis for major depressive disorder. This was found for one (1) of one (1) resident reviewed. Resident identifier: #8. Facility Census: 24. Findings included: a) Resident #8 On 06/26/24 at 1:15 PM on 06/24/24 at 3:48 PM a record review revealed resident was admitted [DATE] with a correct PASARR. On 08/07/17 Resident #8 received a diagnosis of major depressive disorder, recurrent severe with psychotic symptoms. A new PASARR was created after diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms was added. The Director of Nursing (DON) confirmed on 06/26/24 at 1:25 PM a new PASARR was not completed after the resident received a diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms and the care plan was not updated.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This was true for 1 (one) of 12 residents reviewed during the Long Term Care Survey process. Facility census: 24. Resident identifier: Resident #11. Findings include: a) Resident #11 On 06/25/24 at approximately 12:00 PM, a review of Resident #11's medical record was performed. During the review of the Weekly Nursing Summaries, week of 05/08/24-05/11/24, the Weekly Nursing Summary noted Resident #11's skin condition as coccyx breaking down-red, pressure ulcer to outside left ball of foot, dark red. Resident #11 was noted to a care plan with a start date of 01/31/24 revealing the following: Problem: Resident is at high risk for skin breakdown with skin risk assessment 12 with this review, incontinent of bowel and bladder and is…

    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 · D2024-06-27 · 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

    Based on staff interview and observation the facility failed to ensure safe and secure storage (including limited access, and mechanisms to minimize loss or diversion) of all medication. This was a random opportunity for discovery. Facility census: 24. Findings include: a) Facility On 06/26/24 at 07:45 AM, this Surveyor conducted an medication administration with Licensed Practical Nurse (LPN) #51. At the beginning of the medication administration, this Surveyor observed the medication refrigerator and noted the Schedule II-V drugs requiring refrigeration not stored in a box permanently affixed to medication refrigerator. During an interview conducted with the Director of Nursing (DON) on 06/26/24 at approximately 08:20 AM, the DON acknowledged the Schedule II-V drugs requiring refrigeration were not stored in a box permanently affixed to medication refrigerator. The DON stated, We tried to fix it, I don't know how to do it without damaging the refrigerator.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-09-21 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review of facility staffing and staff interview, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. Facility census: 22. Findings included: a) RN coverage Review of the staffing schedules for RN coverage found six (6) occasions, occurring on weekends in July 2022, August 2022, and September 2022, when RN coverage did not occur 8 consecutive hours a day: Saturday, 07/02/22 - RN coverage was 0.00 hours Sunday, 07/03/22 - RN coverage was 0.00 hours Saturday, 08/20/22 - RN coverage was 0.00 hours Sunday, 08/21/22 - RN coverage was 0.00 hours Saturday, 09/10/22 - RN coverage was 0.00 hours Sunday, 09/11/22 - RN coverage was 0.00 hours During an interview on 09/21/22 at 9:20 AM, the Director of Nursing (DON) reported the long-term care unit did not have direct, on-site RN coverage on weekends. The DON explained there was always an RN on the acute care side of the hospital available if necessary. .

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of 12 resident rooms observed during the long term care survey process. Resident Identifier: 14. Facility Census: 22. Findings included: a) Initial Tour of the Facility During the initial tour of the facility on 09/19/22 at 12:08 PM, the following issue was identified: -- The wall behind Resident #14's headboard was painted in an ivory shade and was in poor repair. To the left of the headboard there were two (2) long scratches approximately 12 inches in length and three (3) inches in width. To the right of the headboard there were two (2) scratches approximately six (6) inches in length and two (2) inches in width. These scratches had removed the ivory paint and left a green shade of paint exposed. During a tour with the Director of Nursing at 8:55 AM on 09/20/22, she confirmed the above issues failed to provide a homelike environment to Resident #14 and needed to be repaired. .

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-21 · 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 ensure a resident fall resulting in serious bodily injury and an allegation of verbal abuse by staff, were reported in a timely manner to the appropriate state agencies. The Federal regulation 483.12(c)(1) directs incidents involving serious bodily injury must be reported to the state survey agency within two (2) hours after the injury is noted. The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive the serious bodily injury report within two (2) hours. The guidance also instructs that OHFLAC and APS should receive an allegation of an abuse report within two (2) hours. The failure to make a timely report was true for one (1) of four (4) sampled residents for falls and was true for one (1) of one (1) residents reviewed for abuse. Resident identifiers: #2 and #17. Facility census: 22. Findings included: a) Resident #2 Fall Resulting in Serious Bodily Injury Review…

    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 before2022-09-21 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 — the official record, unedited, may be distressing

    Based on observation, facility documentation review, and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to complete the refrigeration temperature log for the coolers and freezer areas. The practice had the potential to affect a limited number of residents. Facility census: 22. Findings included: a) Temperature Log A review of the September 2022 Walk-In Cooler and Walk-In Freezer Temperature Log, on 09/19/22 at 11:20 AM, revealed the documentation was incomplete. Instructions of the temperature log state temperatures should be taken at 6:00 AM and at 2:00 PM each day. The dates on the temperature log that were incomplete included: --09/18/22 both the AM and PM times were blank --09/19/22 the AM time was blank During an interview, on 09/19/22 at 11:23 AM, the Dietary Supervisor Manager confirmed the temperature log was incomplete and failed to meet professional standards of practice. .

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-21 · 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

    Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record pertaining to a Covid-19 booster. This practice affected one (1) of five (5), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #6. Facility census: #22. Findings included: a) Resident #6 A medical record review on 09/20/22 revealed, Resident #6's immunization record revealed Covid-19 vaccinations: -- Covid-19 #1 vaccine - Moderna on 03/25/21 -- Covid-19 #2 vaccine - Moderna on 04/23/21 -- Booster #1- Moderna on 03/02/22 -- Booster #2- on 08/3/22 Continued review found a nursing progress note, written 09/13/22 at 4:00 PM, Resident received Covid -19 booster in right deltoid no signs or symptoms of adverse reaction. Subsequent review revealed a second nursing progress note, written 09/14/22 at 5:00 PM, no signs or symptoms of adverse reaction to Covid booster. During an interview on 09/21/22 at 12:10 PM the Director of Nursing (DON), stated the nursing progress note was inaccurate. The DON stated that Resident #6 was not given…

    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 · D2022-09-21 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The pneumonia vaccine policy was not updated in accordance with the Center for Disease Control (CDC) recommendations. This practice has the potential to affect all residents. Facility census: 22. Findings include: a) Pneumonia Vaccine The facility policy titled Pneumonia Vaccine with a revision date of October 27, 2015, identifies an order program for the nurses to obtain the order from the physician. The resident or responsible party is to be provided with educational material prior to administration. The policy is not updated to match the Center of Disease (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations on PCV13 (pneumococcal conjugate vaccine 13) vaccine scheduling in older adults. In addition, staff were not utilizing CDC's VIS dated 02/04/2022…

    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 · D2022-09-21 · tag F0888 — isolated
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — the official record, unedited, may be distressing

    Based on facility documentation and staff interview, the facility failed to ensure current staff were fully COVID-19 vaccinated. This was true for one (1) of eight (8) staff members reviewed for compliance with COVID-19 vaccinations. Facility Census: 22. Findings Included: a) Staff Covid-19 Vaccinations Facility documentation review of the facility's Infection control practices found the facility was unable to provide the required staff COVID-19 documentation for completed vaccination in a two-dose series for Environmental Service Attendant #8. Continued review of facility documentation found Nurse Aide #8's first Pfizer vaccine was administered 07/18/22, No second dose was administered. During an interview on 09/21/22 at 12:00 PM the Director of Social Services (SSD) stated that Environmental Service Attendant #8 was only partial vaccinated, and they missed their second dose of the two-dose series. The SSD verified, Environmental Service Attendant #8 was still working in the facility and should have had their second vaccine before 09/06/22. .

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-09-21 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 designate a person to serve as the director of food and nutrition services who was a certified dietary manager within one (1) year of hire. The federal regulation 483.60(a)(2) states: If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who- (i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: A certified dietary manager; or A certified food service manager; or Has similar national certification for food service management and safety from a national certifying body; or Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established…

    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
  • No harm found · C2022-09-21 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP). This failed practice had the potential to affect all residents residing at the facility. Facility Census: 22. Findings included: a) Infection Preventionist Record review of the facility's documentation of Infection control practices found the facility was unable to provide the required Infection Control Preventionist Certification. During an interview on 09/20/22 at 12:13 PM, The Director of Nursing (DON) stated the Infection Preventionist (IP) has completed modules in infection prevention and control, but the IP was going to take the test to get the certificate in November 2022. The DON provided the modules in infection prevention and control, that were completed in March and April of 2019. During an interview on 09/21/21 at approximately 11:30 AM, the Director of Nursing confirmed the facility did not have a Certified Infection Control Preventionist at this time. .

    Infection Control 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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in WV

Paying with Medicaid

CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 51A013. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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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